research study related to nursing

Nursing Research Priorities

Research priorities.

The ANA Enterprise Research Priorities are strategically designed to address critical challenges and opportunities in nursing and healthcare. These priorities focus on enhancing healthcare access, improving safety and quality of care, and promoting the health and well-being of nurses. They also emphasize the importance of diversity, equity, and inclusion, the development of professional identity, and environmental sustainability. Together, these research priorities aim to drive impactful changes that will shape the future of nursing and healthcare on a global scale. Download the full document to learn more about how these priorities are guiding innovative research and advancing the profession.

ANA Enterprise Research Council

The ANA Enterprise Research Advisory Council provides expert guidance and recommendations to the Institute for Nursing Research & Quality Management on matters of global importance, aimed at shaping the future of nursing and healthcare. By fostering a culture of inquiry and advancing interprofessional, practice-based research, the Council drives transformative initiatives that align with the ANA Enterprise's mission to lead the profession forward.

Composed of volunteer experts, the Council unites diverse nursing voices to steer research efforts that strengthen the global impact of nursing. It ensures that frontline nurses' perspectives are central to advancing healthcare innovations. Historically focused on building research capacity, fostering collaboration, and enhancing data governance, the Council's priorities now emphasize workforce development, nurse well-being, diversity and inclusion (DEIB), expanding the scope of practice, and demonstrating the value of nursing.

Research Advisory Council

Jen bonamer.

PhD, RN, AHN-BC, NPD-BC

Nursing Professional Development – Research Specialist Education, Professional Development & Research Department Sarasota Memorial Health Care System

Jen Bonamer works as a Nursing Professional Development – Research Specialist at Sarasota Memorial Hospital in Sarasota Florida. She leads the nursing research and evidence-based practice programs and is actively focused on supporting healthy work environments and clinician well-being. Jen received her BSN from the University of Florida (Gainesville) and practiced for ten years in pediatrics (general practice and hematology/oncology/bone marrow transplant). She completed the University of South Florida’s (Tampa) Nursing BS to PhD program with her master’s of science degree (nursing education) and PhD (nursing). She is certified in both nursing professional development and advanced holistic nursing. Jen is an active member in the American Nurses Association – Enterprise (ANAE) Research Advisory Council and an independent contractor of peer review services for the Magnet program.

Catherine H. Ivory

PhD, RN-BC, NEA-BC, FAAN

Associate Nurse Executive, Nursing Excellence Vanderbilt University Medical Center

Cathy Ivory, PhD, RN-BC, NEA-BC, FAAN, Associate Nurse Executive, oversees the Office of Nursing Excellence for the Vanderbilt Health System. Through collaboration across all VUMC and Vanderbilt University entities, The Office of Nursing Excellence is responsible for professional, evidence-based nursing practice, VUMC’s shared governance and Magnet activities, and all aspects of inquiry that translates evidence into practice and improves quality, safety, patient experience, and the delivery of cost effective care across settings. Dr. Ivory facilitates nursing research activities and connects nurse investigators with collaborators across the broader research enterprise at Vanderbilt.

Dr. Ivory has more than 25 years of experience as a staff nurse, clinical specialist, system-level nursing administrator, educator, and health services researcher. Dr. Ivory’s clinical focus is perinatal nursing and she served as the 2014 President of the Association of Women’s Health, OB and Neonatal Nurses (AWHONN), representing more than 300,000 nurses who care for women and newborns. She also holds two ANCC board certifications, one as an informatics nurse (RN-BC) and one as an advanced nurse executive (NEA-BC). She was inducted as a fellow in the American Academy of Nursing in 2017.

Dr. Ivory holds a BSN, an MSN in nursing administration/healthcare informatics, and a PhD in nursing science. Her research interests include implementation science and using data generated by nurses to quantify their role in patient care, patient safety, and patient outcomes. She is passionate about the nursing profession, nursing informatics, evidence-based nursing practice, and research.

David W. Price

MD, FAAFP, FACEHP, FSACME

Professor, Family Medicine, University of Colorado Anschutz School of Medicine Senior Advisor to the President and CEO, American Board of Family Medicine Medical Education and Quality Improvement Consultant and Coach Associate, Wentz/Miller Global Services

Dr. Price is Senior Advisor to the President, American Board of Family Medicine. He is also Professor of Family Medicine at the University of Colorado School of Medicine.

Dr. Price spent 29 years in the Kaiser Permanente (KP) system in several roles, including Director of Medical Education for the Colorado Region and the (national) Permanente Federation; physician investigator with the KP Colorado Institute of Health Research; Co-director of the Kaiser Colorado Center for Health Education, Dissemination and Implementation research; Clinical Lead for Kaiser National Mental Health Guidelines; member of the Kaiser National Guideline Directors Group, and Chair of Family Medicine for the Colorado Permanente Medical Group. He served on the ABFM Board of Directors from 2003 – 2008, where he chaired the R&D and Maintenance of Certification committees and was Board Chair from 2007-2008. He is a former Senior Vice-President at the American Board of Medical Specialties. He is a past Director of the Accreditation Council for Continuing Medical Education, a past-president of the Colorado Academy of Family Physicians, past chair of the AAMC Group on Educational Affairs section on Continuing Education and Improvement, and currently serves on the AAMC Integrating Quality Initiative steering committee. He is widely published and has spoken nationally and internationally and published in areas ranging from continuing medical education/professional development, quality and practice improvement, mental health, and evidence-based medicine.

Dr. Price received his M.D. degree from Rutgers Medical School in 1985 and completed his Family Medicine Residency and chief residency at JFK Medical Center, Edison, NJ, in 1988. He is a fellow of the American Academy of Family Physicians, the Alliance for Continuing Education in the Health Professions, and the Society of Continuing Medical Education (SACME) and the recipient of the 2018 SACME Distinguished Service in CME Award.

Marianne Weiss

Professor Emerita of Nursing Marquette University College of Nursing

Dr. Weiss is Professor Emerita of Nursing at Marquette University in Milwaukee, WI. She holds a Bachelor of Science in Nursing degree from McGill University in Montreal, Canada, and Master of Science in Nursing and Doctor of Nursing Science degrees from the University of San Diego. Prior to joining the faculty of Marquette University, she held positions as clinical nurse specialist and nurse researcher in women’s services for a large healthcare system.

Dr. Weiss continues to be an active nurse researcher and research consultant. Her program of research focuses on the contribution acute care nurses make to patient outcomes. Much of her work has focused on discharge preparation, assessment of discharge readiness, and post-discharge outcomes across the range of patients discharged from acute care hospitals. Her funded research studied the impact of nurse staffing on quality and cost measures of the discharge transition from hospital to home. Dr. Weiss was the Principal Investigator for the READI multi-site study, commissioned by ANCC and conducted at 33 Magnet hospitals, that investigated implementation of discharge readiness assessment as a standard nursing practice for hospital discharge. Other related research focuses on nurse staffing, continuity of care, and nurse characteristics such as education and certification that contribute to nurse performance in achieving patient outcomes. Her goal is to document the critical role and value hospital nurses bring to patient care and outcomes during and after hospitalization.

Instrument development has been an important aspect of her work on discharge readiness. Dr. Weiss has developed and tested research scales to measure quality of discharge teaching, discharge readiness, and post-discharge coping difficulty. She has conducted tool validation studies in adult-medical surgical patients, parents of hospitalized children, and postpartum mothers. These scales have been translated into more than 15 languages and are being used extensively in clinical practice and research. Dr. Weiss collaborates frequently with researchers worldwide on the science of discharge preparation. She has published extensively with US and international colleagues.

Olga Yakusheva

Professor of Nursing and Public Health Department of Systems, Populations and Leadership Department of Health Management and Policy University of Michigan School of Nursing and School of Public Health

Dr. Yakusheva is an economist with research interests in health economics and health services research. Yakusheva's area of expertise is econometric methods for causal inference, data architecture, and secondary analyses of big data. The primary focus of Yakusheva’s research is the study of economic value of nursing/nurses. Yakusheva pioneered the development of a new method for outcomes-based clinician value-added measurement using the electronic medical records. With this work, Yakusheva was able to measure, for the first time, the value-added contributions of individual nurses to patient outcomes. This work has won her national recognition earning her the Best of AcademyHealth Research Meeting Award in 2014 and a Nomination in 2018. Yakusheva is currently a PI on a AHRQ funded R01 measuring the continuity of interprofessional ICU care and an ANF/ANCC funded research grant measuring the value-added contribution of specialty nurse certifications to nurse performance and patient outcomes.

Yakusheva is a team scientist who has contributed methodological expertise to many interdisciplinary projects including hospital readmissions, primary care providers, obesity, pregnancy and birth, and peer effects on health behaviors and outcomes

Yakusheva holds a PhD in economics, an MS in economic policy, and a BS in applied mathematics.

Colleen K Snydeman

Executive Director, Office of Quality, Safety, Informatics, & Practice and the Inaugural MGH Endowed Scholar in Nursing Practice, Nursing & Patient Care Services, Massachusetts General Hospital

Dr. Snydeman’s expertise and leadership are dedicated to delivering safe, evidenced-based, high quality patient care through the continuous improvement of practice and positive outcomes with a focused commitment to the safety and well-being of the workforce. As the executive director of Massachusetts General Hospital’s Patient Care Services Office of Quality, Safety, Informatics, & Practice I provide oversight for quality and safety programs, improvement initiatives and outcomes associated with quality nursing care (falls, pressure injuries, central line blood stream infections, catheter associated urinary tract infections, and assaults on nursing personnel). I oversee a team of nine quality and informatics specialists and have a formal, non-direct reporting relationship with 75 unit based clinical nurse specialist and nurse practice specialists.

During the unprecedented COVID-19 era I led and supported a full implementation of Circle Up Huddles in all PCS inpatient areas, implementation of hospital-wide Proning Teams (recognized by Johnson & Johnson as a top ten innovation), pressure injury research, qualitative research on the experiences of bedside nurses and respiratory therapists, and implementation of resiliency and wellbeing strategies. In collaboration with RGI analytics, we have developed an algorithm using live streaming electronic health record data to alert nurses on their iphones to changes in patient’s fall risk and the associated interventions needed to prevent falls. Preliminary statistical findings are promising.

I have over forty years of progressive nursing leadership experience. My background in nursing leadership and critical care nursing led to my dissertation work using a quasi-experimental pre/post-test design with intervention and control groups to measure the impact of a theory based adverse event nurse peer review program on safety culture and the recovery of medical errors in the critical care setting. A linear mixed model analysis suggested that critical care nurses who participated in the program had a more critical view of safety culture and work environment, along with increased accountability and responsibility for their role in using strategies to keep patients safe. Further interdisciplinary safety research is underway.

Johana Rocio, Fajardo (Almansa)

Advanced Heart Failure & Transplant Nurse Practitioner, Duke University Hospital

As a doctor of nursing practice with a specialty in heart failure, transplant and mechanical support, my research is focused on improving patient outcomes through the development and implementation of best practices for the care of advanced heart failure patients. My clinical activities are centered on reducing healthcare inequities and improving Health Related Quality of Life (HRQoL) throughout the disease trajectory by optimizing interdisciplinary management and transitional care. Additionally, I have worked on database creation for both clinical and academic purposes as well as leveraging information technology to promote clinical practice standardization, minimize medical errors, and reduce cost of care.

Lastly, I have assisted in the establishment of centers of excellence by building the organizational, clinical, and educational infrastructures to deliver integrative, efficient, and specialized care to the Amyloidosis and Sarcoidosis populations. Furthermore, I have participated as a keynote speaker at national and international medical symposiums and have served as editor in chief and writer of textbooks. During my tenure as an Assistant Professor at Georgetown University School of Medicine, my research focused on the implementation of translational and organizational research to address specific issues in clinical practice and patient care delivery. Additionally, my work in the utilization of Inotropic support in rare cardiomyopathies was recognized as innovative in the field. By providing evidence and simple clinical approaches, this body of work has changed the standards of care for rare cardiomyopathy patients and will continue to provide assistance in relevant medical settings well into the future. I have served in the capacity of Principal Investigator, Co-Investigator, task leader, and technical consultant on projects supported by the government, industry and internal funding sources. In addition, I have successfully collaborated in randomized clinical trial conduction (e.g. patient screening, enrollment, and monitoring), and produced peer-reviewed publications.

Kathy Casey

PhD, RN, NPD-BC

Professional Development Specialist, Denver Health Adjunct Professor, University of Colorado, College of Nursing Adjunct Faculty, Colorado Christian University

Kathy Casey, PhD, RN, NPD-BC, is nationally and internationally known for her Casey-Fink Survey design work supporting graduate nurse role transition, nurse retention, and readiness for professional practice.

Kathy is certified in Nursing Professional Development, and currently serves as a Professional Development Specialist at Denver Health, in Denver, Colorado. She is an Adjunct Professor at the University of Colorado College of Nursing and Adjunct Faculty teaching EBP and Research at Colorado Christian University. Kathy is a lead appraiser for the American Nurses Credentialing Center Practice Transition Accreditation Program (PTAP).

In March 2023, Kathy received the Association for Nursing Professional Development's Marlene Kramer Lifetime Achievement Award for her contributions and research on survey development for use in education and practice programs. In October 2023, Kathy will be inducted as a fellow in the American Academy of Nursing.

Kathy received her Bachelor of Science in Nursing from Pacific Lutheran University, her Master's Degree in Nursing Administration from the University of Colorado, College of Nursing, and her Doctorate in Nursing Education from the University of Northern Colorado, School of Nursing.

Kortney James

PhD, RN, PNP-C

Dr. Kortney James is a PhD prepared nurse and Associate Health Policy Researcher at RAND Corporation. Her research focuses on improving access to quality reproductive health services to minoritized populations. Dr. James is also the Associate Editor of the Nursing for Women's Health Journal, a role in which she is committed to recruiting and supporting manuscripts and research that reflect diverse perspectives and identities. Dr. James recently completed a postdoctoral fellowship in the National Clinician Scholars Program, a continuation of the Robert Wood Johnson Foundation, in the School of Medicine at the University of California, Los Angeles. During her postdoctoral fellowship Dr. James has published several manuscripts in high impact journals. Select publications include "NIH funding: Hone efforts to tackle structural racism" featured in Nature and "Factors associated with postpartum maternal functioning in Black women," featured in Journal of Clinical Medicine. Thus far, Dr. James has been awarded $230,000 to support her research related to Black perinatal mental health. She received $30,000 from the Iris Cantor UCLA Women's Health Center to support her mixed methods study that aims to identify and understand culturally and racially relevant influences on their journey to healing from perinatal mood and anxiety disorders. Dr. James also received $200,000 from the American Nurses Foundation to implement an educational intervention to support ambulatory care nurses and other healthcare staff to care for Black pregnant and postpartum people’s mental health needs with culturally relevant resources. Dr. James has a wide range of clinical experience in acute inpatient care, primary care, and public health. Dr. James is a pediatric nurse practitioner with over a decade of experience in acute newborn care and pediatric primary care. Dr. James has extensive experience in perinatal care due to her time as a registered nurse in the highest volume birthing hospital in the country with an average of around 25,000 births a year (and counting). Dr. James has also held an executive leadership position in the Office of Nursing, Maternal Child Health, and Infectious Disease divisions at the Georgia Department of Public Health in Atlanta, GA.

Ultimately, Dr. James' mission is to co-create solutions with Black women and people capable of pregnancy to achieve health equity.

For questions or inquiries please contact the ANCC Research Council members at [email protected] .

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• Open access
• Published: 28 August 2024

The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students

• Rita Mojtahedzadeh 1 ,
• Tahereh Toulabi 2 , 3 &
• Aeen Mohammadi 1  

BMC Medical Education volume  24 , Article number:  936 ( 2024 ) Cite this article

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Introduction

Studies have reported different results of evaluation methods of clinical competency tests. Therefore, this study aimed to design, implement, and evaluate a blended (in-person and virtual) Competency Examination for final-year Nursing Students.

This interventional study was conducted in two semesters of 2020–2021 using an educational action research method in the nursing and midwifery faculty. Thirteen faculty members and 84 final-year nursing students were included in the study using a census method. Eight programs and related activities were designed and conducted during the examination process. Students completed the Spielberger Anxiety Inventory before the examination, and both faculty members and students completed the Acceptance and Satisfaction questionnaire.

The results of the analysis of focused group discussions and reflections indicated that the virtual CCE was not capable of adequately assessing clinical skills. Therefore, it was decided that the CCE for final-year nursing students would be conducted using a blended method. The activities required for performing the examination were designed and implemented based on action plans. Anxiety and satisfaction were also evaluated as outcomes of the study. There was no statistically significant difference in overt, covert, and overall anxiety scores between the in-person and virtual sections of the examination ( p  > 0.05). The mean (SD) acceptance and satisfaction scores for students in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97), respectively, out of 30 points, in which there was a significant increase in the in-person section compared to the other sections. ( p  = 0.008). The mean acceptance and satisfaction scores for faculty members were 30.31 (4.47) in the virtual, 29.86 (3.94) in the in-person, and 30.00 (4.16) out of 33 in the blended, and there was no significant difference between the three sections ( p  = 0.864).

Evaluating nursing students’ clinical competency using a blended method was implemented and solved the problem of students’ graduation. Therefore, it is suggested that the blended method be used instead of traditional in-person or entirely virtual exams in epidemics or based on conditions, facilities, and human resources. Also, the use of patient simulation, virtual reality, and the development of necessary virtual and in-person training infrastructure for students is recommended for future research. Furthermore, considering that the acceptance of traditional in-person exams among students is higher, it is necessary to develop virtual teaching strategies.

Peer Review reports

The primary mission of the nursing profession is to educate competent, capable, and qualified nurses with the necessary knowledge and skills to provide quality nursing care to preserve and improve the community’s health [ 1 ]. Clinical education is one of the most essential and fundamental components of nursing education, in which students gain clinical experience by interacting with actual patients and addressing real problems. Therefore, assessing clinical skills is very challenging. The main goal of educational evaluation is to improve, ensure, and enhance the quality of the academic program. In this regard, evaluating learners’ performance is one of the critical and sensitive aspects of the teaching and learning process. It is considered one of the fundamental elements of the educational program [ 2 ]. The study area is educational evaluation.

Various methods are used to evaluate nursing students. The Objective Structured Clinical Examination (OSCE) is a valid and reliable method for assessing clinical competence [ 1 , 2 ]. In the last twenty years, the use of OSCE has increased significantly in evaluating medical and paramedical students to overcome the limitations of traditional practical evaluation systems [ 3 , 4 ]. The advantages of this method include providing rapid feedback, uniformity for all examinees, and providing conditions close to reality. However, the time-consuming nature and the need for a lot of personnel and equipment are some disadvantages of OSCE [ 5 , 6 ]. Additionally, some studies have shown that this method is anxiety-provoking for some students and, due to time constraints, being observed by the evaluator and other factors can cause dissatisfaction among students [ 7 , 8 ].

However, some studies have also reported that this method is not only not associated with high levels of stress among students [ 9 ] but also has higher satisfaction than traditional evaluation methods [ 4 ]. In addition, during the COVID-19 pandemic, problems such as overcrowding and student quarantine during the exam have arisen. Therefore, reducing time and costs, eliminating or reducing the tiring quarantine time, optimizing the exam, utilizing all facilities for simulating the clinical environment, using innovative methods for conducting the exam, reducing stress, increasing satisfaction, and ultimately preventing the transmission of COVID-19 are significant problems that need to be further investigated.

Studies show that using virtual space as an alternative solution is strongly felt [ 10 , 11 , 12 ]. In the fall of 2009, following the outbreak of H1N1, educational classes in the United States were held virtually [ 13 ]. Also, in 2005, during Hurricane Katrina, 27 universities in the Gulf of Texas used emergency virtual education and evaluation [ 14 ].

One of the challenges faced by healthcare providers in Iran, like most countries in the world, especially during the COVID-19 outbreak, was the shortage of nursing staff [ 15 , 16 ]. Also, in evaluating and conducting CCE for final-year students and subsequent job seekers in the Clinical Skills Center, problems such as student overcrowding and the need for quarantine during the implementation of OSCE existed. This problem has been reported not only for us but also in other countries [ 17 ]. The intelligent use of technology can solve many of these problems. Therefore, almost all educational institutions have quickly started changing their policies’ paradigms to introduce online teaching and evaluation methods [ 18 , 19 ].

During the COVID-19 pandemic, for the first time, this exam was held virtually in our school. However, feedback from professors and students and the experiences of researchers have shown that the virtual exam can only partially evaluate clinical and practical skills in some stations, such as basic skills, resuscitation, and pediatrics [ 20 ].

Additionally, using OSCE in skills assessment facilitates the evaluation of psychological-motor knowledge and attitudes and helps identify strengths and weaknesses [ 21 ]. Clinical competency is a combination of theoretical knowledge and clinical skills. Therefore, using an effective blended method focusing on the quality and safety of healthcare that measures students’ clinical skills and theoretical expertise more accurately in both in-person and virtual environments is essential. The participation of students, professors, managers, education and training staff, and the Clinical Skills Center was necessary to achieve this important and inevitable goal. Therefore, the Clinical Competency Examination (CCE) for nursing students in our nursing and midwifery school was held in the form of an educational action research process to design, implement, and evaluate a blended method. Implementing this process during the COVID-19 pandemic, when it was impossible to hold an utterly in-person exam, helped improve the quality of the exam and address its limitations and weaknesses while providing the necessary evaluation for students.

The innovation of this research lies in evaluating the clinical competency of final-year nursing students using a blended method that focuses on clinical and practical aspects. In the searches conducted, only a few studies have been done on virtual exams and simulations, and a similar study using a blended method was not found.

The research investigates the scientific and clinical abilities of nursing students through the clinical competency exam. This exam, traditionally administered in person, is a crucial milestone for final-year nursing students, marking their readiness for graduation. However, the unforeseen circumstances of the COVID-19 pandemic and the resulting restrictions rendered in-person exams impractical in 2020. This necessitated a swift and significant transition to an online format, a decision that has profound implications for the future of nursing education. While the adoption of online assessment was a necessary step to ensure student graduation and address the nursing workforce shortage during the pandemic, it was not without its challenges. The accurate assessment of clinical skills, such as dressing and CPR, proved to be a significant hurdle. This underscored the urgent need for a change in the exam format, prompting a deeper exploration of innovative solutions.

To address these problems, the research was conducted collaboratively with stakeholders, considering the context and necessity for change in exam administration. Employing an Action Research (AR) approach, a blend of online and in-person exam modalities was adopted. Necessary changes were implemented through a cyclic process involving problem identification, program design, implementation, reflection, and continuous evaluation.

The research began by posing the following questions:

What are the problems of conducting the CCE for final-year nursing students during COVID-19?

How can these problems be addressed?

What are the solutions and suggestions from the involved stakeholders?

How can the CCE be designed, implemented, and evaluated?

What is the impact of exam type on student anxiety and satisfaction?

These questions guided the research in exploring the complexities of administering the CCE amidst the COVID-19 pandemic and in devising practical solutions to ensure the validity and reliability of the assessment while meeting stakeholders’ needs.

Materials and methods

Research setting, expert panel members, job analysis, and role delineation.

This action research was conducted at the Nursing and Midwifery School of Lorestan University of Medical Sciences, with a history of approximately 40 years. The school accommodates 500 undergraduate and graduate nursing students across six specialized fields, with 84 students enrolled in their final year of undergraduate studies. Additionally, the school employs 26 full-time faculty members in nursing education departments.

An expert panel was assembled, consisting of faculty members specializing in various areas, including medical-surgical nursing, psychiatric nursing, community health nursing, pediatric nursing, and intensive care nursing. The panel also included educational department managers and the examination department supervisor. Through focused group discussions, the panel identified and examined issues regarding the exam format, and members proposed various solutions. Subsequently, after analyzing the proposed solutions and drawing upon the panel members’ experiences, specific roles for each member were delineated.

Sampling and participant selection

Given the nature of the research, purposive sampling was employed, ensuring that all individuals involved in the design, implementation, and evaluation of the exam participated in this study.

The participants in this study included final-year nursing students, faculty members, clinical skills center experts, the dean of the school, the educational deputy, group managers, and the exam department head. However, in the outcome evaluation phase, 13 faculty members participated in-person and virtually (26 times), and 84 final-year nursing students enrolled in the study using a census method in two semesters of 2020–2021 completed the questionnaires, including 37 females and 47 males. In addition, three male and ten female faculty members participated in this study; of this number, 2 were instructors, and 11 were assistant professors.

Data collection tools

In order to enhance the validity and credibility of the study and thoroughly examine the results, this study utilized a triangulation method consisting of demographic information, focus group discussions, the Spielberger Anxiety Scale questionnaire, and an Acceptance and Satisfaction Questionnaire.

Demographic information

A questionnaire was used to gather demographic information from both students and faculty members. For students, this included age, gender, and place of residence, while for faculty members, it included age, gender, field of study, and employment status.

Focus group discussion

Multiple focused group discussions were conducted with the participation of professors, administrators, experts, and students. These discussions were held through various platforms such as WhatsApp Skype, and in-person meetings while adhering to health protocols. The researcher guided the talks toward the research objectives and raised fundamental questions, such as describing the strengths and weaknesses of the previous exam, determining how to conduct the CCE considering the COVID-19 situation, deciding on virtual and in-person stations, specifying the evaluation checklists for stations, and explaining the weighting and scoring of each station.

Spielberger anxiety scale questionnaire

This study used the Spielberger Anxiety Questionnaire to measure students’ overt and covert anxiety levels. This questionnaire is an internationally standardized tool known as the STAI questionnaire that measures both overt (state) and covert (trait) anxiety [ 22 ]. The state anxiety scale (Form Y-1 of STAI) comprises twenty statements that assess the individual’s feelings at the moment of responding. The trait anxiety scale (Form Y-2 of STAI) also includes twenty statements that measure individuals’ general and typical feelings. The scores of each of the two scales ranged from 20 to 80 in the current study. The reliability coefficient of the test for the apparent and hidden anxiety scales, based on Cronbach’s alpha, was confirmed to be 0.9084 and 0.9025, respectively [ 23 , 24 ]. Furthermore, in the present study, Cronbach’s alpha value for the total anxiety questionnaire, overt anxiety, and covert anxiety scales were 0.935, 0.921, and 0.760, respectively.

Acceptance and satisfaction questionnaire

The Acceptability and Satisfaction Questionnaire for Clinical Competency Test was developed by Farajpour et al. (2012). The student questionnaire consists of ten questions, and the professor questionnaire consists of eleven questions, using a four-point Likert scale. Experts have confirmed the validity of these questionnaires, and their Cronbach’s alpha coefficients have been determined to be 0.85 and 0.87 for the professor and student questionnaires, respectively [ 6 ]. In the current study, ten medical education experts also confirmed the validity of the questionnaires. Regarding internal reliability, Cronbach’s alpha coefficients for the student satisfaction questionnaire for both virtual and in-person sections were 0.76 and 0.87, respectively. The professor satisfaction questionnaires were 0.84 and 0.87, respectively. An online platform was used to collect data for the virtual exam.

Data analysis and rigor of study

Qualitative data analysis was conducted using the method proposed by Graneheim and Lundman. Additionally, the criteria established by Lincoln and Guba (1985) were employed to confirm the rigor and validity of the data, including credibility, transferability, dependability, and confirmability [ 26 ].

In this research, data synthesis was performed by combining the collected data with various tools and methods. The findings of this study were reviewed and confirmed by participants, supervisors, mentors, and experts in qualitative research, reflecting their opinions on the alignment of findings with their experiences and perspectives on clinical competence examinations. Therefore, the member check method was used to validate credibility.

Moreover, efforts were made in this study to provide a comprehensive description of the research steps, create a suitable context for implementation, assess the views of others, and ensure the transferability of the results.

Furthermore, researchers’ interest in identifying and describing problems, reflecting, designing, implementing, and evaluating clinical competence examinations, along with the engagement of stakeholders in these examinations, was ensured by the researchers’ long-term engagement of over 25 years with the environment and stakeholders, seeking their opinions and considering their ideas and views. These factors contributed to ensuring confirmability.

In this research, by reflecting the results to the participants and making revisions by the researchers, problem clarification and solution presentation, design, implementation, and evaluation of operational programs with stakeholder participation and continuous presence were attempted to prevent biases, assumptions, and research hypotheses, and to confirm dependability.

Data analysis was performed using SPSS version 21, and descriptive statistical tests (absolute and relative frequency, mean, and standard deviation) and inferential tests (paired t-test, independent t-test, and analysis of variance) were used. The significance level was set at 0.05. Parametric tests were used based on the normality of the data according to the Kolmogorov-Smirnov statistical test.

Given that conducting the CCE for final-year nursing students required the active participation of managers, faculty members, staff, and students, and to answer the research question “How can the CCE for final-year nursing students be conducted?” and achieve the research objective of “designing, implementing, and evaluating the clinical competency exam,” the action research method was employed.

The present study was conducted based on the Dickens & Watkins model. There are four primary stages (Fig.  1 ) in the cyclical action research process: reflect, plan, act, observe, and then reflect to continue through the cycle [ 27 ].

The cyclical process of action research [ 27 ]

Stage 1: Reflection

Identification of the problem.

According to the educational regulations, final semester nursing students must complete the clinical competency exam. However, due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person was not feasible.

This exam was conducted virtually at our institution. However, based on the reflections from experts, researchers have found that virtual exams can only partially assess clinical and practical skills in certain stations, such as basic skills, resuscitation, and pediatrics. Furthermore, utilizing Objective Structured Clinical Examination (OSCE) in skills assessment facilitates the evaluation of psychomotor skills, knowledge, and attitudes, aiding in identifying strengths and weaknesses.

P3, “Due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person is not feasible.”

Stage 2: Planning

Based on the reflections gathered from the participants, the exam was designed using a blended approach (combining in-person and virtual components) as per the schedule outlined in Fig.  2 . All planned activities for the blended CCE for final-year nursing students were executed over two semesters.

P5, “Taking the exam virtually might seem easier for us and the students, but in my opinion, it’s not realistic. For instance, performing wound dressing or airway management is very practical, and it’s not possible to assess students with a virtual scenario. We need to see them in person.”

P6"I believe it’s better to conduct those activities that are highly practical in person, but for those involving communication skills like report writing, professional ethics, etc., we can opt for virtual assessment.”

Design and implementation of the blended CCE

Stage 3: Act

Cce implementation steps.

The CCE was conducted based on the flowchart in Fig.  3 and the following steps:

Steps for conducting the CCE for final-year nursing students using a blended method

Step 1: Designing the framework for conducting the blended Clinical Competency Examination

The panelists were guided to design the blended exam in focused group sessions and virtual panels based on the ADDIE (Analysis, Design, Development, Implementation, Evaluation) model [ 28 ]. Initially, needs assessment and opinion polling were conducted, followed by the operational planning of the exam, including the design of the blueprint table (Table  1 ), determination of station types (in-person or virtual), designing question stems in the form of scenarios, creating checklists and station procedure guides by expert panel groups based on participant analysis, and the development of exam implementation guidelines with participant input [ 27 ]. The design, execution, and evaluation were as follows:

In-person and virtual meetings with professors were held to determine the exam schedule, deadlines for submitting checklists, decision-making regarding the virtual or in-person nature of stations based on the type of skill (practical, communication), and presenting problems and solutions. Based on the decisions, primary skill stations, as well as cardiac and pediatric resuscitation stations, were held in person. In contrast, virtual stations for health, nursing ethics, nursing reports, nursing diagnosis, physical examinations, and psychiatric nursing were held.

News about the exam was communicated to students through the college website and text messages. Then, an online orientation session was held on Skype with students regarding the need assessment of pre-exam educational workshops, virtual and in-person exam standards, how to use exam software, how to conduct virtual exams, explaining the necessary infrastructure for participating in the exam by students, completing anxiety and satisfaction questionnaires, rules and regulations, how to deal with rejected individuals, and exam testing and Q&A. Additionally, a pre-exam in-person orientation session was held.

To inform students about the entire educational process, the resources and educational content recommended by the professors, including PDF files, photos and videos, instructions, and links, were shared through a virtual group on the social media messenger, and scientific information was also, questions were asked and answered through this platform.

Correspondence and necessary coordination were made with the university clinical skills center to conduct in-person workshops and exams.

Following the Test-centered approach, the Angoff Modified method [ 29 , 30 ] was used to determine the scoring criteria for each station by panelists tasked with assigning scores.

Additionally, in establishing standards for this blended CCE for fourth-year nursing students, for whom graduation was a prerequisite, the panelists, as experienced clinical educators familiar with the performance and future roles of these students and the assessment method of the blended exam, were involved [ 29 , 30 ](Table 1 ).

Step 2: Preparing the necessary infrastructure for conducting the exam

Software infrastructure.

The pre- and post-virtual exam questions, scenarios, and questionnaires were uploaded using online software.

The exam was conducted on a trial basis in multiple sessions with the participation of several faculty members, and any issues were addressed. Students were authenticated to enter the exam environment via email and personal information verification. The questions for each station were designed and entered into the software by the respective station instructors and the examination coordinator, who facilitated the exam. The questions were formatted as clinical scenarios, images, descriptive questions, and multiple-choice questions, emphasizing the clinical and practical aspects. This software had various features for administering different types of exams and various question formats, including multiple-choice, descriptive, scenario-based, image-based, video-based, matching, Excel output, and graphical and descriptive statistical analyses. It also had automatic questionnaire completion, notification emails, score addition to questionnaires, prevention of multiple answer submissions, and the ability to upload files up to 4 gigabytes. Student authentication was based on national identification numbers and student IDs, serving as user IDs and passwords. Students could enter the exam environment using their email and multi-level personal information verification. If the information did not match, individuals could not access the exam environment.

Checklists and questionnaires

A student list was prepared, and checklists for the in-person exam and anxiety and satisfaction questionnaires were reproduced.

Empowerment workshops for professors and education staff

Educational needs of faculty members and academic staff include conducting clinical competency exams using the OSCE method; simulating and evaluating OSCE exams; designing standardized questions, checklists, and scenarios; innovative approaches in clinical evaluations; designing physical spaces and setting up stations; and assessing ethics and professional commitment in clinical competency exams.

Student empowerment programs

According to the students’ needs assessment results, in-person workshops on cardiopulmonary resuscitation and airway management and online workshops were held on health, pediatrics, cardiopulmonary resuscitation, ethics, nursing diagnosis, and report writing through Skype messenger. In addition, vaccination notes, psychiatric nursing, and educational files on clinical examinations and basic skills were recorded by instructors and made available to students via virtual groups.

Step 3: CCE implementation

The CCE was held in two parts, in-person and virtual.

In-person exam

The OSCE method was used for this section of the exam. The basic skills station exam included dressing and injections, and the CPR and pediatrics stations were conducted in person. The students were divided into two groups of 21 each semester, and the exam was held in two shifts. While adhering to quarantine protocols, the students performed the procedures for seven minutes at each station, and instructors evaluated them using a checklist. An additional minute was allotted for transitioning to the next station.

Virtual exam

The professional ethics, nursing diagnosis, nursing report, health, psychiatric nursing, and physical examination stations were conducted virtually after the in-person exam. This exam was made available to students via a primary and a secondary link in a virtual space at the scheduled time. Students were first verified, and after the specified time elapsed, the ability to respond to inactive questions and submitted answers was sent. During the exam, full support was provided by the examination center.

The examination coordinator conducted the entire virtual exam process. The exam results were announced 48 h after the exam. A passing grade was considered to be a score higher than 60% in all stations. Students who failed in various stations were given the opportunity for remediation based on faculty feedback, either through additional study or participation in educational workshops. Subsequent exams were held one week apart from the initial exam. It was stipulated that students who failed in more than half of the stations would be evaluated in the following semester. If they failed in more than three sessions at a station, a decision would be made by the faculty’s educational council. However, no students met these situations.

Step 4: Evaluation

The evaluation of the exam was conducted by examiners using a checklist, and the results were announced as pass or fail.

Stage 4: Observation / evaluation

In this study, both process and outcome evaluations were conducted:

Process evaluation

All programs and activities implemented during the test design and administration process were evaluated in the process evaluation. This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups.

Sample reflections received from faculty members, managers, experts, and students through group discussions and social messaging platforms after the changes:

P7: “The implementation of the blended virtual exam, in the conditions of the COVID-19 crisis where the possibility of holding in-person exams was not fully available, in my opinion, was able to improve the quality of exam administration and address the limitations and weaknesses of the exam entirely virtually.”

P5: “In my opinion, this blended method was able to better evaluate students in terms of clinical readiness for entering clinical practice.”

Outcomes evaluation

The study outcomes were student anxiety, student acceptance and satisfaction, and faculty acceptance and satisfaction. Before the start of the in-person and virtual exams, the Spielberger Anxiety Questionnaire was provided to students. Additionally, immediately after the exam, students and instructors completed the acceptance and satisfaction questionnaire for the relevant section. After the exam, students and instructors completed the acceptance and satisfaction questionnaire again for the entire exam process, including feasibility, satisfaction with its implementation, and educational impact.

Design framework and implementation for the blended Clinical Competency Examination

The exam was planned using a blended method (part in-person, part virtual) according to the Fig.  2 schedule, and all planned programs for the blended CCE for final-year nursing students were implemented in two semesters.

Evaluation results

In this study, 84 final-year nursing students participated, including 37 females (44.05%) and 47 males (55.95%). Among them, 28 (33.3%) were dormitory residents, and 56 (66.7%) were non-dormitory residents.

In this study, both process and outcome evaluations were conducted.

All programs and activities implemented during the test design and administration process were evaluated in the process evaluation (Table  2 ). This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups on social media.

Anxiety and satisfaction were examined and evaluated as study outcomes, and the results are presented below.

The paired t-test results in Table  3 showed no statistically significant difference in overt anxiety ( p  = 0.56), covert anxiety ( p  = 0.13), and total anxiety scores ( p  = 0.167) between the in-person and virtual sections before the blended Clinical Competency Examination.

However, the mean (SD) of overt anxiety in persons in males and females was 49.27 (11.16) and 43.63 (13.60), respectively, and this difference was statistically significant ( p  = 0.03). Also, the mean (SD) of overt virtual anxiety in males and females was 45.70 (11.88) and 51.00 (9.51), respectively, and this difference was statistically significant ( p  = 0.03). However, there was no significant difference between males and females regarding covert anxiety in the person ( p  = 0.94) and virtual ( p  = 0.60) sections. In addition, the highest percentage of overt anxiety was apparent in the virtual section among women (15.40%) and the in-person section among men (21.28%) and was prevalent at a moderate to high level.

According to Table  4 , One-way analysis of variance showed a significant difference between the virtual, in-person, and blended sections in terms of acceptance and satisfaction scores.

The results of the One-way analysis of variance showed that the mean (SD) acceptance and satisfaction scores of nursing students of the CCE in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97) out of 30, respectively. There was a significant difference between the three sections ( p  = 0.008).

In addition, 3 (7.23%) male and 10 (76.3%) female faculty members participated in this study; of this number, 2 (15.38%) were instructors, and 11 (84.62%) were assistant professors. Moreover, they were between 29 and 50 years old, with a mean (SD) of 41.37 (6.27). Furthermore, they had 4 to 20 years of work experience with a mean and standard deviation of 13.22(4.43).

The results of the analysis of variance showed that the mean (SD) acceptance and satisfaction scores of faculty members of the CCE in virtual, in-person, and blended sections were 30.31 (4.47), 29.86 (3.94), and 30.00 (4.16) out of 33, respectively. There was no significant difference between the three sections ( p  = 0.864).

This action research study showed that the blended CCE for nursing students is feasible and, depending on the conditions and objectives, evaluation stations can be designed and implemented virtually or in person.

The blended exam, combining in-person and virtual elements, managed to address some of the weaknesses of entirely virtual exams conducted in previous terms due to the COVID-19 pandemic. Given the pandemic conditions, the possibility of performing all in-person stations was not feasible due to the risk of students and evaluators contracting the virus, as well as the need for prolonged quarantine. Additionally, to meet the staffing needs of hospitals, nursing students needed to graduate. By implementing the blended exam idea and conducting in-person evaluations at clinical stations, the assessment of nursing students’ clinical competence was brought closer to reality compared to the entirely virtual method.

Furthermore, the need for human resources, station setup costs, and time spent was less than the entirely in-person method. Therefore, in pandemics or conditions where sufficient financial resources and human resources are not available, the blended approach can be utilized.

Additionally, the evaluation results showed that students’ total and overt anxiety in both virtual and in-person sections of the blended CCE did not differ significantly. However, the overt anxiety of female students in the virtual section and male students in the in-person section was considerably higher. Nevertheless, students’ covert anxiety related to personal characteristics did not differ in virtual and in-person exam sections. However, students’ acceptance and satisfaction in the in-person section were higher than in the virtual and blended sections, with a significant difference. The acceptance and satisfaction of faculty members from the CCE in in-person, virtual, and blended sections were the same and relatively high.

A blended CCE nursing competency exam was not found in the literature review. However, recent studies, especially during the COVID-19 pandemic, have designed and implemented this exam using virtual OSCE. Previously, the CCE was held in-person or through traditional OSCE methods.

During the COVID-19 pandemic, nursing schools worldwide faced difficulties administering clinical competency exams for students. The virtual simulation was used to evaluate clinical competency and develop nursing students’ clinical skills in the United States, including standard videos, home videos, and clinical scenarios. Additionally, an online virtual simulation program was designed to assess the clinical competency of senior nursing students in Hong Kong as a potential alternative to traditional clinical training [ 31 ].

A traditional in-person OSCE was also redesigned and developed through a virtual conferencing platform for nursing students at the University of Texas Medical Branch in Galveston. Survey findings showed that most professors and students considered virtual OSCE a highly effective tool for evaluating communication skills, obtaining a medical history, making differential diagnoses, and managing patients. However, professors noted that evaluating examination techniques in a virtual environment is challenging [ 32 ].

However, Biranvand reported that less than half of the nursing students believed the in-person OSCE was stressful [ 33 ]. At the same time, the results of another study showed that 96.2% of nursing students perceived the exam as anxiety-provoking [ 1 ]. Students believe that the stress of this exam is primarily related to exam time, complexity, and the execution of techniques, as well as confusion about exam methods [ 7 ]. In contrast to previous research results, in a study conducted in Egypt, 75% of students reported that the OSCE method has less stress than other examination methods [ 9 ]. However, there has yet to be a consensus across studies on the causes and extent of anxiety-provoking in the OSCE exam. In a study, the researchers found that in addition to the factors mentioned above, the evaluator’s presence could also be a cause of stress [ 34 ]. Another survey study showed that students perceived the OSCE method as more stressful than the traditional method, mainly due to the large number of stations, exam items, and time constraints [ 7 ]. Another study in Egypt, which designed two stages of the OSCE exam for 75 nursing students, found that 65.6% of students reported that the second stage exam was stressful due to the problem-solving station. In contrast, only 38.9% of participants considered the first-stage exam stressful [ 35 ]. Given that various studies have reported anxiety as one of the disadvantages of the OSCE exam, in this study, one of the outcomes evaluated was the anxiety of final-year nursing students. There was no significant difference in total anxiety and overt anxiety between students in the in-person and virtual sections of the blended Clinical Competency Examination. The overt anxiety was higher in male students in the in-person part and female students in the virtual section, which may be due to their personality traits, but further research is needed to confirm this. Moreover, since students’ total and overt anxiety in the in-person and virtual sections of the exam are the same in resource and workforce shortages or pandemics, the blended CCE is suggested as a suitable alternative to the traditional OSCE test. However, for generalization of the results, it is recommended that future studies consider three intervention groups, where all OSCE stations are conducted virtually in the first group, in-person in the second group, and a blend of in-person and virtual in the third group. Furthermore, the results of the study by Rafati et al. showed that the use of the OSCE clinical competency exam using the OSCE method is acceptable, valid, and reliable for assessing nursing skills, as 50% of the students were delighted, and 34.6% were relatively satisfied with the OSCE clinical competency exam. Additionally, 57.7% of the students believed the exam revealed learning weaknesses [ 1 ]. Another survey study showed that despite higher anxiety about the OSCE exam, students thought that this exam provides equal opportunities for everyone, is less complicated than the traditional method, and encourages the active participation of students [ 7 ]. In another study on maternal and infant care, 95% of the students believed the traditional exam only evaluates memory or practical skills. In contrast, the OSCE exam assesses knowledge, understanding, cognitive and analytical skills, communication, and emotional skills. They believed that explicit evaluation goals, appropriate implementation guidelines, appropriate scheduling, wearing uniforms, equipping the workroom, evaluating many skills, and providing fast feedback are among the advantages of this exam [ 36 ]. Moreover, in a survey study, most students were satisfied with the clinical environment offered by the OSCE CCE using the OSCE method, which is close to reality and involves a hypothetical patient in necessary situations that increase work safety. On the other hand, factors such as the scheduling of stations and time constraints have led to dissatisfaction among students [ 37 ].

Furthermore, another study showed that virtual simulations effectively improve students’ skills in tracheostomy suctioning, triage concepts, evaluation, life-saving interventions, clinical reasoning skills, clinical judgment skills, intravenous catheterization skills, role-based nursing care, individual readiness, critical thinking, reducing anxiety levels, and increasing confidence in the laboratory, clinical nursing education, interactive communication, and health evaluation skills. In addition to knowledge and skills, new findings indicate that virtual simulations can increase confidence, change attitudes and behaviors, and be an innovative, flexible, and hopeful approach for new nurses and nursing students [ 38 ].

Various studies have evaluated the satisfaction of students and faculty members with the OSCE Clinical Competency Examination. In this study, one of the evaluated outcomes was the acceptability and satisfaction of students and faculty members with implementing the CCE in blended, virtual, and in-person sections, which was relatively high and consistent with other studies. One crucial factor that influenced the satisfaction of this study was the provision of virtual justification sessions for students and coordination sessions with faculty members. Social messaging groups were formed through virtual and in-person communication, instructions were explained, expectations and tasks were clarified, and questions were answered. Students and faculty members could access the required information with minimal presence in medical education centers and time and cost constraints. Moreover, with the blended evaluation, the researcher’s communication with participants was more accessible. The written guidelines and uploaded educational content of the workshops enabled students to save the desired topics and review them later if needed. Students had easy access to scientific and up-to-date information, and the application of social messengers and Skype allowed for sending photos and videos, conducting workshops, and questions and answering questions. However, the clinical workshops and examinations were held in-person to ensure accuracy. The virtual part of the examination was conducted through online software, and questions focused on each station’s clinical and practical aspects. Students answered various questions, including multiple-choice, descriptive, scenario, picture, and puzzle questions, within a specified time. The blended examination evaluated clinical competency and did not delay these individuals’ entry into the job market. Moreover, during the severe human resource shortage faced by the healthcare system, the examination allowed several nurses to enter the country’s healthcare system. The blended examination can substitute in-person examination in pandemic and non-pandemic situations, saving facilities, equipment, and human resources. The results of this study can also serve as a model to guide other nursing departments that require appropriate planning and arrangements for Conducting Clinical Competency Examinations in blended formats. This examination can also be developed to evaluate students’ clinical performance.

One of the practical limitations of the study was the possibility that participants might need to complete the questionnaires accurately or be concerned about losing marks. Therefore, in a virtual session before the in-person exam, the objectives and importance of the study were explained. Participants were assured that it would not affect their evaluation and that they should not worry about losing marks. Additionally, active participation from all nursing students, faculty members, and staff was necessary for implementing this plan, achieved through prior coordination, virtual meetings, virtual group formation, and continuous reflection of results, creating the motivation for continued collaboration and participation.

Among other limitations of this study included the use of the Spielberger Anxiety Questionnaire to measure students’ anxiety. It is suggested that future studies use a dedicated anxiety questionnaire designed explicitly for pre-exam anxiety measurement. Another limitation of the current research was its implementation in nursing and midwifery faculty. Therefore, it is recommended that similar studies be conducted in nursing and midwifery faculties of other universities, as well as in related fields, and over multiple consecutive semesters. Additionally, for more precise effectiveness assessment, intervention studies in three separate virtual, in-person, and hybrid groups using electronic checklists are proposed. Furthermore, it is recommended that students be evaluated in terms of other dimensions and variables such as awareness, clinical skill acquisition, self-confidence, and self-efficacy.

Conducting in-person Clinical Competency Examination (CCE) during critical situations, such as the COVID-19 pandemic, is challenging. Instead of virtual exams, blended evaluation is a feasible approach to overcome the shortages of virtual ones and closely mimic in-person scenarios. Using a blended method in pandemics or resource shortages, it is possible to design, implement, and evaluate stations that evaluate basic and advanced clinical skills in in-person section, as well as stations that focus on communication, reporting, nursing diagnosis, professional ethics, mental health, and community health based on scenarios in a virtual section, and replace traditional OSCE exams. Furthermore, the use of patient simulators, virtual reality, virtual practice, and the development of virtual and in-person training infrastructure to improve the quality of clinical education and evaluation and obtain the necessary clinical competencies for students is recommended. Also, since few studies have been conducted using the blended method, it is suggested that future research be conducted in three intervention groups, over longer semesters, based on clinical evaluation models and influential on other outcomes such as awareness and clinical skill acquisition self-efficacy, confidence, obtained grades, and estimation of material and human resources costs. This approach reduced the need for physical space for in-person exams, ensuring participant quarantine and health safety with higher quality. Additionally, a more accurate assessment of nursing students’ practical abilities was achieved compared to a solely virtual exam.

Data availability

The datasets generated and analyzed during the current study are available on request from the corresponding author.

Rafati F, Pilevarzade M, Kiani A. Designing, implementing and evaluating once to assess nursing students’ clinical competence in Jiroft faculty of nursing and midwifery. Nurs Midwifery J. 2020;18(2):118–28.

Google Scholar  

Sadeghi T, Ravari A, Shahabinejad M, Hallakoei M, Shafiee M, Khodadadi H. Performing of OSCE method in nursing students of Rafsanjan University of Medical science before entering the clinical field in the year 2010: a process for quality improvement. Community Health J. 2012;6(1):1–8.

Ali GA, Mehdi AY, Ali HA. Objective structured clinical examination (OSCE) as an assessment tool for clinical skills in Sohag University: nursing students’ perspective. J Environ Stud. 2012;8(1):59–69.

Article   Google Scholar  

Bolourchifard F, Neishabouri M, Ashktorab T, Nasrollahzadeh S. Satisfaction of nursing students with two clinical evaluation methods: objective structured clinical examination (OSCE) and practical examination of clinical competence. Adv Nurs Midwifery. 2010;19(66):38–42.

Noohi E, Motesadi M, Haghdoost A. Clinical teachers’ viewpoints towards Objective Structured Clinical examination in Kerman University of Medical Science. Iran J Med Educ. 2008;8(1):113–20.

Reza Masouleh S, Zare A, Chehrzad M, Atrkarruoshan Z. Comparing two methods of evaluation, objective structured practical examination and traditional examination, on the satisfaction of students in Shahid Beheshti faculty of nursing and midwifery. J Holist Nurs Midwifery. 2008;18(1):22–30.

Bagheri M, Sadeghineajad Forotagheh M, Shaghayee Fallah M. The comparison of stressors in the assessment of basic clinical skills with traditional method and OSCE in nursing students. Life Sci J. 2012;9(4):1748–52.

Eldarir SH, El Sebaae HA, El Feky HA, Hussein HA, El Fadil NA, El Shaeer IH. An introduction of OSCE versus the traditional method in nursing education: Faculty capacity building and students’ perspectives. J Am Sci. 2010;6(12):1002–14.

Al-Zeftawy AM, Khaton SE. Student evaluation of an OSCE in Community Health nursing clinical course at Faculty of nursing, Tanta University. J Nurs Health Sci. 2016;5(4):68–76.

Hayter M, Jackson D. Pre-registration undergraduate nurses and the COVID-19 pandemic: students or workers? J Clin Nurs. 2020;29(17–18):3115–6.

Bayham J, Fenichel EP. Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modeling study. Lancet Public Health. 2020;5(5):e271–8.

Murphy MPA. COVID-19 and emergency eLearning: consequences of the securitization of higher education for post-pandemic pedagogy. Contemp Secur Policy. 2020;41(3):492–505.

Allen IE, Seaman J. Learning on demand: Online education in the United States, 2009.

Meyer KA, Wilson JL. The role of Online Learning in the emergency plans of Flagship Institutions. Online J Distance Learn Adm. 2011;14(1):110–8.

Kursumovic E, Lennane S, Cook TM. Deaths in healthcare workers due to COVID-19: the need for robust data and analysis. Anaesthesia. 2020;75(8):989–92.

Malekshahi Beiranvand F, Hatami Varzaneh A. Health care workers challenges during coronavirus outbreak: the qualitative study. J Res Behav Sci. 2020;18(2):180–90.

Boursicot K, Kemp S, Ong TH, Wijaya L, Goh SH, Freeman K, Curran I. Conducting a high-stakes OSCE in a COVID-19 environment. MedEdPublish. 2020;9:285–89.

Atwa H, Shehata MH, Al-Ansari A, Kumar A, Jaradat A, Ahmed J, Deifalla A, Online. Face-to-Face, or blended learning? Faculty and Medical Students’ perceptions during the COVID-19 pandemic: a mixed-method study. Front Med. 2022;9:791352.

Chan MMK, Yu DS, Lam VS, Wong JY. Online clinical training in the COVID-19 pandemic. Clin Teach. 2020;17(4):445–6.

Toulabi T, Yarahmadi S. Conducting a clinical competency test for nursing students in a virtual method during the Covid-19 pandemic: a case study. J Nurs Educ. 2021;9(5):33–42.

Meskell P, Burke E, Kropmans TJB, Byrne E, Setyonugroho W, Kennedy KM. Back to the future: an online OSCE Management Information System for nursing OSCEs. Nurse Educ Today. 2015;35(11):1091–6.

Lichtenberg PA. (2010). Handbook of Assessment in Clinical Gerontology, 2nd Ed. Academic Press, https://doi.org/10.1016/B978-0-12-374961-1.10030-2

Gholami Booreng F, Mahram B, Kareshki H. Construction and validation of a scale of research anxiety for students. IJPCP. 2017;23(1):78–93.

Esmaili M. A survey of the influence of Murita therapy on reducing the rate of anxiety in clients of counseling centers. Res Clin Psychol Couns. 2011;1(1):15–30.

Farajpour A, Amini M, Pishbin E, Arshadi H, Sanjarmusavi N, Yousefi J, Sarafrazyazdi M. Teachers’ and students’ satisfaction with DOPS Examination in Islamic Azad University of Mashhad, a study in Year 2012. Iran J Med Educ. 2014;14(2):165–73.

StraussAC, Corbin JM. Basics of qualitative research: grounded theory procedures and technique. 2nd ed. London: Sage, Newbury Park; 1998.

Dickens L, Watkins K. Action research: rethinking Lewin. Manage Learn. 1999;30(2):127–40.

Rezaeerad M, Nadri Kh, Mohammadi Etergoleh R. The effect of ADDIE (analysis, design, development, implementation, evaluation) designing method with emphasizing on mobile learning on students’ self-conception, development motivation and academic development in English course. Educational Adm Res Q. 2013;4(15):15–32.

Ben-David MF. AMEE Guide 18: standard setting in student assessment. Med Teach. 2000;22(2):120–30.

McKinley DW, Norcini JJ. How to set standards on performance-based examinations: AMEE Guide 85. Med Teach. 2014;36(2):97–110.

Fung JTC, Zhang W, Yeung MN, Pang MTH, Lam VSF, Chan BKY, Wong JYH. Evaluation of students perceived clinical competence and learning needs following an online virtual simulation education programmed with debriefing during the COVID-19 pandemic. Nurs Open. 2021;8(6):3045–54.

Luke S, Petitt E, Tombrella J, McGoff E. Virtual evaluation of clinical competence in nurse practitioner students. Med Sci Educ. 2021;31:1267–71.

Beiranvand SH, Hosseinabadi R, Ghasemi F, Anbari KH. An Assessment of nursing and Midwifery Student Veiwwpoin, Performance, and feedback with an objective structured clinical examination. J Nurs Educ. 2017;6(1):63–7.

Sheikh Abumasoudi R, Moghimian M, Hashemi M, Kashani F, Karimi T, Atashi V. Comparison of the Effect of Objective Structured Clinical evaluation (OSCE) with Direct and Indirect Supervision on nursing student’s test anxiety. J Nurs Educ. 2015;4(2):1–8.

Zahran EM, Taha EE. Students’ feedback on Objective Structured Clinical examinations (OSCEs) experience in emergency nursing. J High Inst Public Health. 2009;39(2):370–87.

Na A-G. Assessment of Students’ knowledge, clinical performance and satisfaction with objective structured clinical exam. Med J Cairo Univ. 2009;77(4):287–93.

Adib-Hajbaghery M, Yazdani M. Effects of OSCE on learning, satisfaction and test anxiety of nursing students: a review study. Iran J Med Educ. 2018;18:70–83.

Purwanti LE, Sukartini T, Kurniawati ND, Nursalam N, Susilowati T. Virtual Simulation in clinical nursing education to improve knowledge and clinical skills: Literature Review. Open Access Maced J Med Sci. 2022;10(F):396–404.

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Acknowledgements

We want to thank the Research and Technology deputy of Smart University of Medical Sciences, Tehran, Iran, the faculty members, staff, and officials of the School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran, and all individuals who participated in this study.

All steps of the study, including study design and data collection, analysis, interpretation, and manuscript drafting, were supported by the Deputy of Research of Smart University of Medical Sciences.

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Tahereh Toulabi

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RM. Participating in study design, accrual of study participants, review of the manuscript, and critical revisions for important intellectual content. TT : The investigator; participated in study design, data collection, accrual of study participants, and writing and reviewing the manuscript. AM: Participating in study design, data analysis, accrual of study participants, and reviewing the manuscript. All authors read and approved the final version of the manuscript.

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This action research was conducted following the participatory method. All methods were performed according to the relevant guidelines and regulations in the Declaration of Helsinki (ethics approval and consent to participate). The study’s aims and procedures were explained to all participants, and necessary assurance was given to them for the anonymity and confidentiality of their information. The results were continuously provided as feedback to the participants. Informed consent (explaining the goals and methods of the study) was obtained from participants. The Smart University of Medical Sciences Ethics Committee approved the study protocol (IR.VUMS.REC.1400.011).

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Mojtahedzadeh, R., Toulabi, T. & Mohammadi, A. The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students. BMC Med Educ 24 , 936 (2024). https://doi.org/10.1186/s12909-024-05935-9

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DOI : https://doi.org/10.1186/s12909-024-05935-9

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A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

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• v.6(3); 2019 Jul

Nursing research: A marriage of theoretical influences

Kari toverud jensen.

1 Oslo Metropolitan University, Oslo, Norway

Associated Data

The aim is to examine PhD theses in nursing science, their purpose or aim and the theoretical approaches and methods employed. The study seeks to examine how such theses may be categorized, what they study, what theoretical approaches they employ and, in particular, to what degree nursing theory is employed as a current theoretical approach.

This study has a descriptive qualitative design.

This study complied with the Standard for Reporting Qualitative Research (SRQR). Data were collected from 61 PhD theses in nursing science published from 1994–2015, at University of Edinburgh.

Twenty of the PhD theses used theoretical approaches with a sociological perspective and 12 used a psychological perspective. Eighteen of the PhD theses were based on theoretical approaches from philosophy, ethics, pedagogy, medicine or biology as a primary perspective. Nursing theories, in their conventional definition, have a limited presence in the theses examined.

1. INTRODUCTION

Nursing as a profession is changing as other health professions work with and alongside nurses in practice, and patients' knowledge levels have improved. The number of nursing scientists has increased, and research knowledge and skills have improved. Nursing research happens in an increasingly diverse research community with colleagues from other disciplines, often in an international context. In an interdisciplinary environment, the theoretical basis of nursing, as opposed to other disciplines, may be obscured. Nursing research plays a role in developing the theoretical basis of nursing, but this may not be explicit in the way nursing research is conducted.

2. BACKGROUND

As described by Alligood ( 2013 ), a result of the recognition of nursing as an academic field of study is that nursing theories have become more important in nursing science. However, what is the prevalence of nursing theories in nursing science? A literature study by Bond et al. ( 2011 ), looking at articles from seven leading nursing journals, found that 21% of the articles used nursing theory. In her review of US doctoral dissertation abstracts in nursing (2000–2004), Spear ( 2007 ) found that less than one‐third referred to nursing theories or theory development in their abstracts. About 45% referred to non‐nursing theory, with psychosocial theories the most prevalent. Lundgren, Valmari, and Skott ( 2009 ) found that dissertations in Nordic countries completed in 2003 were more likely to have nursing practice as their core, while “nursing concepts and theories” (p. 413) received less attention.

However, beyond the studies mentioned, few have been preoccupied with the theoretical approaches in nursing science. Heyman ( 1995 ) has conducted a study of Swedish nursing and caring research across 65 doctoral theses written by nurses from 1974–1991. She found that the researchers had been inspired by different sciences, belonging to at least one of the two divergent traditions, either biomedical research or the social sciences. The study indicates heterogeneity in theoretical conditions, methodologies, rationales and structures across the PhD theses studied. Yarcheski, Mahon, and Yarcheski ( 2012 ) concluded, in a study of research published in scientific nursing journals, that there was a trend towards less theoretically oriented research and that “the study of psychological variables has dominated the last 20 years (1990–2010) of nursing research” (p. 1,120). In addition, Yarcheski and Mahon ( 2013 ) concluded, in a study of characteristics of quantitative nursing research between 1990–2010, that while quantitative nursing research in general could be defined as multidisciplinary, the discipline of psychology dominated throughout the research literature. Larsen and Adamsen ( 2009 ) studied the emergence of Nordic nursing research. They found three distinct positions operating in nursing research: a clinical and applied position closely connected to clinical contexts or practices, a profession and knowledge position focused on frameworks of knowledge and its dissemination and a theoretical and concept position. The theoretical and conceptual positions were used to describe, explain and interpret practice.

After the 1980s, the number of PhD graduates in nursing has increased worldwide. Doctoral theses are an important source in the interpretation of the development in most sciences. Accordingly, the production of PhD dissertations is crucial for nursing science, as well as the building of a body of knowledge important for education, clinical practice and patient outcomes. In this study of nursing science, I have selected data from doctoral theses in nursing from the University of Edinburgh because this university is of special interest for European nursing as it was one of Europe's first universities to introduce nursing science as an academic discipline in their academic body. The university has a long history and decades of influence on nursing research both in the UK and in Europe. It has been educating doctoral candidates in nursing science since 1959 and established, in 1972, the first professorship in nursing studies in Europe (Anderson, Lynch, & Phillipson, 2003 ). Nursing studies at the University of Edinburgh are, as of 2002, located in the School of Health in Social Science; until 2002, the studies were located in the Faculty of Social Sciences (ibid), which may account for the close relationship with the social sciences. An interesting distinction in theoretical approaches is the one between the social sciences and the biomedical sciences (Heyman, 1995 ) and how the different PhD theses shape the field of nursing, through nursing research and theoretical approaches.

In order to understand the implementation of a scientific approach to nursing, PhD theses have in small‐scale been studied and we lack this type of empirical study also from the UK. The aim of this paper is to examine PhD theses in nursing science, their purpose or aim and the theoretical approaches and methods employed. The study seeks to examine how such theses may be categorized, what they study, what theoretical approaches they employ and, in particular, to what degree nursing theory is employed as a current theoretical approach. Nursing theory has been a contested concept. Meleis ( 2012 ) emphasizes that the “multiple use of concepts to describe the same set of relationships has resulted in more confusion” (p. 29). To meet this challenge, the present study will examine the use of the concept “nursing theory” as what the PhD researchers define as content.

This study has a descriptive qualitative design, with PhD theses in nursing science as data sources. The data underwent analysis, inspired by Braun and Clarke ( 2006 ), Hsieh and Shannon ( 2005 ) and Heyman ( 1995 ).

3.1. Method

Data were collected from 61 PhD theses in nursing science published from 1994–2015. The number of PhD theses represents the total number completed during the period in nursing studies at University of Edinburgh. A total of 101 doctoral theses have been submitted from 1959–2015. The decision to include PhD theses from 1994–2015 resulted in a convenience sample reflecting the field of nursing research following the British “Project 2000: a new preparation for practice” (Fawcett, Waugh, & Smith, 2016 ). This study complied with the Standard for Reporting Qualitative Research (SRQR; O'Brien, Harris, Beckman, Reed, & Cook, 2014 ; File S1 ).

3.2. Data analysis

The coding of texts is inspired by Braun and Clarke's ( 2006 ) thematic analysis involving identifying, analysing and reporting patterns in data. While such an analysis may be inductive or deductive, in this study the analysis is deductive in nature. In the first phase, the PhD theses' abstracts were read, followed by a reading of sections of the thesis, such as summary, background and the theory chapter. In the second phase, the PhD theses were systematically analysed by applying three categories to the collected data: the field of study, the aim/purpose of the study and the research methodology. The summative content analysis, inspired by Hsieh and Shannon ( 2005 ), was used to identify and quantify the concept “nursing theory(ies)”.

The third phase involved the coding, inspired by Heyman's ( 1995 ) characteristics of the affiliation to different disciplines' perspectives, in the theoretical approaches or the field of study of the theses. Heyman identified how nursing researchers have studied the human being from many perspectives, including biological and medical, psychological, sociological, organizational and ethical (as a cultural perspective), in addition to pedagogical perspectives. To identify the theoretical perspective or field of study, information from PhD theses, such as use of concepts, models, theories and references to theorists, was collated in a data matrix and structured. The matrix also recorded author, year, title, aims, research questions, findings and type of PhD thesis (monograph or articles). The data, related to theory, models and concepts, as well as references to theorists, were compiled and classified. In the fourth phase, the collected data were reviewed multiple times in order to define the theoretical approaches of the dissertations. Most of the theses' theoretical approaches were obvious and some used multiple approaches. As an example, McGrath's ( 2006 ) PhD thesis, using both sociological theories of identity and psychology, is described in Table ​ Table1, 1 , whereas the main approach is identified as sociological in accordance with the phases described above. Data collection took place through the Centre of Research Collection, University of Edinburgh, from October 2015–April 2016.

PhD theses: aim, theoretical approach, method and use of nursing theory

Use of NT (how many times the concept nursing theory is used in the PhD text not included reference lists), — refer to “not access” on internet databases.

3.3. Ethical approval

Investigating one's peers' research work is important and requires curiosity, interest and respect for other perspectives. I have not changed the candidates' names but have presented them as official literature sources. All readers may therefore check the PhD theses used in this study to assess how they have been treated, analysed and interpreted. This study is approved by the Norwegian Centre for Research Data, project number 51425.

All 61 PhD theses examined were written as monographs, which is an atypical form compared with the Nordic countries (Larsen & Adamsen, 2009 ), where article‐based PhD theses make up the vast majority. Twenty of the PhD theses used theoretical approaches with a sociological perspective and 12 used a psychological perspective. Eighteen of the PhD theses were based on theoretical approaches from philosophy, ethics, pedagogy, medicine or biology as a primary perspective. Two PhD theses used a theoretical approach with a cultural or linguistic perspective, and the organizational perspective was used by seven PhD theses. An “other” category was created to accommodate the theses that did not fit into any established category. “Others” represented just two PhD theses, one using nursing theories of spiritual care and another exploring historical sources. The PhD theses thematically described, investigated, explored, uncovered, examined, compared, identified, determined, provided, created, developed, generated, extended, measured or contributed to advanced understanding of the challenges faced by patients, the changes associated with illness as disease, sickness and experience and how nurses can help, intervene and alleviate; what nurses and nurse students do when they are nursing and preparing for nursing; and the interaction between patients and nurses.

The Internet and the search function were helpful in examining the use of the concept «nursing theory» in the PhD theses. Of the 61 PhD theses examined, 54 were available on the Internet and were included in this concept search (7 March 2018; https://www.era.lib.ed.ac.uk/ ). In the 54 accessible PhD theses, the concept “nursing theory/theories” was referred to by 13 authors. Five theses referred to the concept more than once. In addition, one thesis used “theory of caring” as one of the theoretical approaches and mentioned it 11 times (Frei, 2005 ). Most of the theses used theoretical approaches based on non‐nursing disciplines (Table ​ (Table1). 1 ). Post‐2005, nursing theory is referred to in only two of 26 theses accessible online (Table ​ (Table2 2 ).

Summarizing through the years; field of study, methods and references to nursing theory

Qualitative research methods were the most commonly used methodologies (43 of 61 PhD theses used qualitative methods; Table ​ Table2). 2 ). Prior to 2000, the dissertations were inspired more by organizational and psychological theoretical approaches and showed more diversity in the use of methods compared with after 2000, when the use of sociological and philosophical approaches increased, as did the extensive use of qualitative methods. The 5‐year period preceding 2015 shows a trend of a greater use of mixed methods.

5. DISCUSSION

This study reveals that different scientific disciplines, traditions and abstraction levels informed the PhD theses we examined. Only a few of the PhD theses referred to nursing theory and even fewer used it as their theoretical approach, or as part of the theoretical approach (Table ​ (Table1; 1 ; Everingham, 2012 ; Frei, 2005 ; Grosvenor, 2005 ; Hogg, 2002 ; Rukholm, 1999 ). Most authors used theories based in disciplines other than nursing as theoretical approaches for studying their topic. Risjord ( 2011 ) claims that “it is a mistake to suppose that a theory is either a nursing theory or a non‐theory; disciplines do not own theories” (p. 517). McEven and Wills ( 2014 ) discuss the use of shared or borrowed theories used by nurse researchers and tried to identify what the application of different theories means for nursing. They argue that use of theory offers structure and organization to nursing knowledge and promotes rational and systematic practice and make nursing practice more purposeful, coordinated and less fragmented. Meleis ( 2012 ) brings in another point of view when she states that “all theories used in nursing to understand, explain, predict, or change nursing phenomena are nursing theories” (p. 35), wherever they may have originated.

This study confirms the limited references to nursing theories and shows that after 2005, such references are only rarely present. Why is this? Most nursing theories were developed in the USA, with roots tracing back to the 1980s and earlier. The nursing education systems in the USA differ from those in the UK and Europe in general, and these differences might also have affected the type of theoretical approaches used. Another reason might be that methods and theories from related sciences frame some nursing research questions better. The limited use of, or references to, nursing theories might also reflect a perception that using such theories does not aid the study of nursing practice or the nursing context. As explained by Risjord ( 2010 ), this might historically relate to the relevance gap between the professional nurses' need of knowledge and the nursing theorists' knowledge production. Critical voices have also claimed that nursing theories have no relevance as tools in nursing practice and that clinically based nurses find nursing theory to be of no practical value, useful only as an academic abstraction separating theory from everyday practice (Doane & Varcoe, 2005 ). According to Alligood ( 2014 ), these assumptions undermine a rationale for developing nursing theories as a means of facing challenges in nursing practice and patient care more confidently. These perspectives will have consequences for education and leadership in nursing.

The use of sociological theories represents 20 of the theses. This is perhaps not surprising, considering that nursing studies at the University of Edinburgh are affiliated with the social sciences. More importantly though, the sociological approach emphasizes the interaction between human society and individuals, which is valuable for the subject of nursing and its impact on individuals, families, groups and societal health and well‐being. According to Laiho ( 2010 ), nursing science is clearly a social discipline, motivated to develop itself through the influence of social interests and goals. Nursing research with a sociological approach is crucial in order to consider social factors and issues that prevent, constrain and promote societal health behaviours (Laiho, 2010 ). An example is Muangman ( 2014 ), who studied the nature of “emotion work” in the context of care among adult stroke survivors aged 18–59 and their carers, situated in Thailand. This helped advance knowledge and understanding of the interaction between stroke survivors and their carers, the sociology of family, helping nurses to better facilitate and optimize their nursing and family care.

The use of psychological theory represents 12 of the studied doctoral theses. This is not surprising. Psychology or behavioural science theories are often used by nurse researchers, especially the theories surrounding stress and/or coping. An example here is Kilbride's ( 2006 ) PhD thesis. This study explored changes in neurological function and the emotional challenges experienced by patients with malignant glioma and their families, during the time period between surgery and radiotherapy. In addition to measuring changes in neurological functional status, the researcher used a coping framework to examine practical and emotional issues. This is relevant knowledge for nursing practice to anticipate and predict the physical and emotional responses of patients and their carers and to contribute to optimal quality of life for both patients and relatives.

Philosophical/ethical theory defined nine theses, with most of them leaning more towards the philosophical. Philosophy is defined by Teichman and Evans ( 1999 ) as “… a study of problems that are ultimate, abstract and general. These problems are concerned with the nature of existence, knowledge, morality, reason and human purpose” (p. 1). Adamson's ( 2015 ) study explored the shared experiences of one woman's experience with ovarian cancer from diagnosis to death, using philosophical theories. Adamson used the insights from German idealism (18th century) as a framework for understanding the aesthetics of how to live and die. In this context, philosophy brings to light knowledge on how to identify what is valuable and essential for this woman and her partner. Nurses need such knowledge to better understand, be prepared for and better care for both patients and their families during the disease trajectory.

Organizational theories were employed by seven PhD theses that looked at different applications of management and administration. One example is Miller ( 2004 ), who studied the processes of Trust managers and how they handle incidents involving qualified nurses, as well as how the outcomes of these processes are used to inform the organization and to develop new models of management. Leading an organization, which many nurses do, requires knowledge of, for instance, theories of error as employed by Miller ( 2004 ). Such theories allow nurses to be better prepared and develop strategies to improve leadership, change, decision‐making and motivation in the repertoire of practice among advanced nursing practitioners (McEven & Wills, 2014 ).

Fields of study in culture and linguistics were represented by two PhD theses. One of them, Quickfall ( 2009 ), studied cross‐cultural promotion of health, investigating issues underlying culturally competent nursing for asylum seekers. Knowledge from such theses has implications for all healthcare professions, including nurses, in providing culturally sensitive and evidence‐based nursing, regardless of geographic location (McEven & Wills, 2014 ).

Important aspects of nursing, including promoting health, advising patients and clients how to live with their illness and teaching nurse students, were addressed by four PhD theses. In the investigation of such phenomena, pedagogy and learning theories contribute to a scientific understanding of nurses in their teaching endeavours. Examples of the use of learning theory include the thesis by Msiska ( 2012 ), who explored the clinical learning experiences of undergraduate student nurses in Malawi and Nugent ( 2014 ), who studied the interactive effects of the construction of a special learning theory in relation to predicting health behaviour when supporting patients with type 2 diabetes mellitus in Scotland.

The last field of study is medicine and biology, used by five PhD theses. An example is Bailey ( 1998 ), who developed a description of the acute exacerbation event of Chronic Obstructive Pulmonary Disease to assist nurses in their work with the patient and their families. Bailey used a theoretical model of managing a medical crisis. The development of knowledge in this field has implications for clinical practice. Nurses need deep knowledge about how to manage crises to ensure the best care for patients and their families in acute situations.

As indicated, the nursing programme at the University of Edinburgh is affiliated with the social sciences, owing to its inclusion in the School of Health in Social Science. This affiliation may have influenced the choice of theoretical approaches in the examined PhD theses' nursing research. This might represent a distinctiveness associated with the location of the PhD programmes in nursing science, either in independent faculties or as a part of other disciplines' PhD programmes. In this study, most of the PhD theses were included in the collective term social sciences and only a few in medicine or biology. With regard to this, the findings in this study diverge from the results of Heyman ( 1995 ), who found that the theoretical approaches fell within either biomedical research or the social sciences.

According to Silverman ( 2011 ), “the facts that we find in ‘the field' never speak for themselves but are impregnated by our own assumptions” (p. 38). The facts remain the challenges faced by patients, the changes associated with illness as disease, sickness and experience and how nurses can help, in their research focus, which the present study has shown.

Complex tasks often require a heterogeneous knowledge base. They require that a professional practitioner in the actual action situation is able to coordinate and merge various forms of disciplinary and practice‐based knowledge. Professional occupation can therefore not be reduced to a question of the relationship between “theory” and “practice”. It is actually not just about applying theoretical knowledge in practical situations. Describing theories used exclusively in nursing research as nursing theory (Meleis, 2012 ) is not seen as a fruitful way to discuss the theoretical challenges in nursing science. The use of different theoretical approaches in nursing research, as the results of this study show, reveals the different theoretical approaches' importance for the development of advanced nursing knowledge as a support for nursing practice. Nursing science originates in a heterogeneous and fragmented body of knowledge, which this study of PhD theses also reflects. According to Risjord ( 2010 ), nursing knowledge will be strengthened when theory is shared with other disciplines, not weakened.

Nursing research is an amalgamation, inspired by a broad range of theories and methodological approaches. This status is what brought nursing to its present academic level: scientific nursing journals, PhD programmes, professors, nursing institutes and faculties. Risjord ( 2011 ) asks “does nursing science need a distinct kind of theory?” (p. 489). It is interesting that nursing research does not seem to rest on one distinct kind of theory. Most of the theses in this study do not refer to or use nursing theory as a theoretical approach. There is quite simply a gradual reduction in direct reference to nursing theory over time.

Professions, such as nursing, are characterized by heterogeneous and fragmented bodies of knowledge and there is no one theory used, but nursing is rather enacted in the application of multiple theories (Grimen, 2008 ). In general, PhD theses represent the scientification of nursing, understood as a scientific contribution to the improvement of nursing knowledge and nursing practice, through an increase in research‐based knowledge. A seemingly natural extension is that increased research activities, given their importance to nursing practice, will boost the nursing reputation and its position in the health research landscape.

6. CONCLUSION

This study concludes that most PhD theses have aims and research questions connected to nursing contexts and practices and are thus nursing related. All the theses studied can be seen as appropriate contributions to improving a general body of knowledge, driven by nursing research.

A relevant question generating from this study is whether the failure to relate research to nursing theory has meant that the traditional nursing theories are obsolete and outdated? It might look that way. However, we need more research to investigate this very question, both empirically and theoretically. The present study investigated all PhD theses on nursing‐related issues, all most likely increasing the knowledge base in nursing practice. Nursing research and nursing science offer a different perspective on health through examining nursing phenomena and posing research questions from a nursing perspective. The PhD theses examined in this study applied a wide variety of theories from other disciplines. The core principle of developing the theoretical basis for nursing and nursing knowledge remains, however, to advance and support nursing practice.

7. LIMITATIONS

The strength of this study is the access to all of the PhD theses from the University of Edinburgh and the Centre of Research Collection. The systematic descriptions in Table ​ Table1 1 strengthen the transparency of this study. The weakness of this study lies, however, also in this interpretive table, as some of the PhD theses combined different fields of study, such as Robertson ( 2007 ), who used both sociological and psychological theories. I chose to include Robertson's study in the field of sociology based on its thematic issues, a subjective decision that is open for discussion.

The selection of only one university for examination may also be considered a weakness. However, the University of Edinburgh has contributed pioneering work in building nursing science in Europe. It therefore represents an important and interesting institution for the investigation of nursing studies. Further research is, however, required to present a more complete picture of nursing researchers' use of theoretical approaches in their research.

CONFLICT OF INTEREST

There were no conflicts of interest associated with this study.

Supporting information

Acknowledgement.

I want to thank Professor Tonks Fawcett, University of Edinburgh, and Professor Kristian Larsen, Aalborg University, for their important comments and inspiration.

Jensen KT. Nursing research: A marriage of theoretical influences . Nursing Open . 2019; 6 :1205–1217. 10.1002/nop2.320 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

• Adamson, V. M. F. (2015). The dance to death: The aesthetic experience of dying . Doctoral Thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/12237 [ Google Scholar ]
• Adhikari, R. (2011). From aspirations to ‘dream‐trap': Nurse education in Nepal and Nepali nurse migration to the UK . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/6199 [ Google Scholar ]
• Allbutt, H. (2008). The experience of illness and employment among young adults with a long‐term condition . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Alligood, M. R. (2013). Nursing theory: Utilization & application (5th ed.). St. Lois, MO: Elsevier. [ Google Scholar ]
• Alligood, M. R. (2014). Nursing theorists and their work (8th ed.). St Louis, MO: Elsevier. [ Google Scholar ]
• Anderson R. D., Lynch M., & Phillipson N. (Eds.) (2003). The University of Edinburgh: An illustrated history . Edinburgh, UK: Edinburgh University Press. [ Google Scholar ]
• Bailey, P. (1998). Patients', family caregivers' and nurses' stories of acute exacerbation events of chronic obstructive pulmonary disease . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/21379 [ Google Scholar ]
• Bauld, L. C. (1998). Older patient participation in multi‐disciplinary decision‐making: Discharge planning in Scotland and British Columbia, Canada . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/21490 [ Google Scholar ]
• Beil‐Hildebrand, M. (2001). Instilling and distilling a reputation for institutional excellence: A critical reflection on organising practice . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/22566 [ PubMed ] [ Google Scholar ]
• Bond, A. E. , Eshah, N. F. , Bani‐Khaled, M. , Hamad, A. O. , Habashneh, S. , Kataua', H. , … Maabreh, R. (2011). Who uses nursing theory? A univariate descriptive analysis of five years' research articles . Scandinavian Journal of Caring Sciences , 25 ( 2 ), 404–409. 10.1111/j.1471-6712.2010.00835.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Braun, R. (1996). The ontology of the person: The basic for commitive and creative moral agency in nursing practice . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/21643 [ Google Scholar ]
• Braun, V. , & Clarke, V. (2006). Using thematic analysis in psychology . Qualitative Research in Psychology , 3 , 77–101. 10.1191/1478088706qp063oa [ CrossRef ] [ Google Scholar ]
• Calman, L. (2004). Patients' views of nurses' clinical competence: A grounded theory approach . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/24043 [ Google Scholar ]
• Cameron, S. (1994). First‐time mothers and their health visitors: Perceptions of a home visit . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Doane, G. H. , & Varcoe, C. (2005). Toward compassionate action: Pragmatism and the inseparability of theory/practice . ANS Advances in Nursing Science , 28 ( 1 ), 81–90. 10.1097/00012272-200501000-00009 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Du, J. (2014). The unrecognized role: Hospital‐based nurses' experiences of health promotion . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/24543 [ Google Scholar ]
• Everingham, K. L. (2012). Phenomenological exploration of clinical decision making of Intensive Care Unit (ICU) nurses in relation to sedation management . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/7773 [ Google Scholar ]
• Fawcett, T. N. , Waugh, A. , & Smith, G. D. (2016). The primacy of the bioscineces: A forgotten in nurse education? Journal of Clinical Nursing , 25 , 2680–2682. 10.1111/jocn.13484 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ferguson, C. (2000). The student experience of preceptorship in nursing: Learning through guided participation . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/22204 [ Google Scholar ]
• Freer, Y. (1997). Breastfeeding in premature infants: A descriptive study . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/21245 [ Google Scholar ]
• Frei, I. A. (2005). First‐time mothers' experiences and the perception of nurses' provision of postnatal care . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Glaser, B. G. , & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research . New York, NY: Aldine de Gruyter. [ Google Scholar ]
• Greig, C. (2002). Prenatal preparation of parents for neonatal intensive care: A comparative descriptive study . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/23031 [ Google Scholar ]
• Grimen, H. (2008). Profesjon og kunnskap [Profession and knowledge] In Molander A., & Terum L. I. (Eds.), Profesjonsstudier [Studies on professions] (pp. 71–86). Oslo, Norway: Universitetsforlaget. [ Google Scholar ]
• Grosvenor, D. (2005). Care matters: Spiritual care by nurses from feminist perspectives . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/1263 [ Google Scholar ]
• Haraldsdottir, E. (2007). The constraints of the ordinary: Caring for dying patients in an inpatient hospice . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Haycock‐Stuart, E. (1999). Sense and Susceptibility: How Mothers view Accidental Injury Risk and Develop Safety Strategies for Pre‐School Children . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Heyman, I. (1995). Gånge hatt till…: omvårdsforskning framväxt I Sverige – sjuksköterskors avhandlingar 1974–1991 . (The emergence of nursing research in Sweden: Doctoral theses written by nurses, 1974–1991). Doctoral thesis. University of Stockholm. [ Google Scholar ]
• Hockley, J. (2006). Developing high quality end‐of‐life care in nursing homes: An action research study . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Hogg, R. M. (2002). An analysis of parents' experience of parenthood and of the health visiting service, from the perspectives of young children . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Horsburg, D. (2001). Student Nurses' Perceptions of Patient/Client Care: A Qualitative Analysis . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/23056 [ Google Scholar ]
• Howell, J. (2006). An analysis of the involvement of community nurses in clinical governance . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Hsieh, H. F. , & Shannon, S. E. (2005). Three approaches to qualitative content analysis . Qualitative Health Research , 15 ( 9 ), 1277–1288. 10.1177/1049732305276687 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Immenschuh, U. (2003). ‘ My arm and leg – They are just sleeping': Perspectives of younger people on their experience of having a stroke . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/724 [ Google Scholar ]
• Kadmon, I. (1994). Breast cancer: Women's experiences of decision‐making and the role of the nurse counsellor . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/19885 [ Google Scholar ]
• Kasidi, E. (2009). Exploring the meaning of participation in nursing care: The old persons' perspective in the community . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Kean, S. (2007). The emergence of negotiated family care in intensive care – a grounded theory approach . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Kilbride, L. (2006). An examination of the period between surgery and radiotherapy for patients with malignant glioma and their families . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/24774 [ Google Scholar ]
• Kydonaki, K. (2011). Decision‐making processes of weaning from mechanical ventilation: A comparative ethnographic insight into the dynamics of the decision‐making environment . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/5925 [ Google Scholar ]
• Laiho, A. (2010). Academisation of nursing education in the Nordic countries . Higher Education , 60 , 641–656. 10.1007/s10734-010-9321-y [ CrossRef ] [ Google Scholar ]
• Larsen, K. , & Adamsen, L. (2009). Emergence of Nordic nursing research: No position is an Island . Scandinavian Journal of Caring Sciences , 23 , 757–766. 10.1111/j.1471-6712.2008.00676.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lau, A. (2011). Perspectives of Chinese couples on their experience of Assisted Reproductive technology (ART) treatment . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Lucas, B. J. (2002). Playing the game: Undergraduate student nurses' perceptions of reflective journals . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/23098 [ Google Scholar ]
• Lugton, J. (1994). The meaning of social support: A descriptive study of informal networks and of health visitors' formal role in supporting the identity of woman with breast cancer . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/20638 [ Google Scholar ]
• Lundgren, S. , Valmari, G. , & Skott, C. (2009). The nature of nursing research: Dissertations in the Nordic countries, 2003 . Scandinavian Journal of Caring Sciences , 23 , 402–416. 10.1111/j.1471-6712.2008.00631.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• MacLaren, J. (2013). Making sense of supervision: A narrative study of the supervision experiences of mental health nurses and midwives . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from http://hdl.handle.net/1842/9826 [ Google Scholar ]
• McEven, M. , & Wills, E. M. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins. [ Google Scholar ]
• McGrath, A. (2006). Should I stay or should I go? Towards an understanding of leaving nursing . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/3178 [ Google Scholar ]
• Meleis, A. I. (2012). Theoretical nursing development & progress (5th ed). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins. [ Google Scholar ]
• Mennie, M. E. (1995). Prenatal screening for cystic fibrosis: Implications for maternity care . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/20687 [ Google Scholar ]
• Merriweather, J. (2014). Exploration of the factors that influence nutritional recovery following critical illness: A mixed methods study . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from http://hdl.handle.net/1842/9571 [ Google Scholar ]
• Miller, J. (2004). Risk management and nursing . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Mortimer, B. (2002). The nurse in Edinburgh c 1760–1860: The impact of commerce and professionalisation . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Msiska, G. (2012). Exploring the clinical learning experience: Voices of Malawian undergraduate student nurses . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/7772 [ Google Scholar ]
• Muangman, M. (2014). Life after stroke: An ethnomethodological study of emotion work among adult stroke survivors and their carers in rural areas of Nakhon Sawan Province, Thailand . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/16459 [ Google Scholar ]
• Mueller, M. (1995). Organizing participation: An ethnography of ‘Community' in Hospital . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/21438 [ Google Scholar ]
• Mulgrew, F. (2002). Learning to recover. Patients accounts of their post‐surgery experience . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/25004 [ Google Scholar ]
• Ng, W. I. (2013). Exploratory trial for examining effects of self‐management education programme on patients with chronic obstructive pulmonary disease in Macau . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/26010 [ Google Scholar ]
• Nugent, L. (2014). Interaction of health value and perceived control in relation to outcome behaviours in a type 2 diabetes patient population in Scotland . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/9830 [ Google Scholar ]
• O'Brien, B. C. , Harris, I. B. , Beckman, T. J. , Reed, D. A. , & Cook, D. A. (2014). Standards for reporting qualitative research: A synthesis of recommendations . Academic Medicine , 89 ( 9 ), 1245–1251. 10.1097/ACM.0000000000000388 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Paxton, F. M. (1998). Practice nursing: A time of change: A study of nursing in general practice . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/22550 [ Google Scholar ]
• Quickfall, J. (2009). Cross‐cultural promotion of health: A partnership process? Principles and factors involved in the culturally competent community based nursing care of asylum applicants in Scotland . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/4466 [ Google Scholar ]
• Ramsay, P. (2010). Quality of life following prolonged critical illness: A mixed methods study . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/8310 [ Google Scholar ]
• Rhynas, S. (2010). ‘Forgotten shopping, lost keys and hearts which forget to beat': An exploration of nurses' conceptualisation of dementia . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/4494 [ Google Scholar ]
• Risjord, M. (2010). Nursing knowledge: Science, practice, and philosophy . Chichester, UK: Wiley‐Blackwell. [ Google Scholar ]
• Risjord, M. (2011). Nursing science In Gifford F. (Ed.), Philosophy of Medicine (Handbook of the philosophy of science) (Volume 16 ). North Holland, Netherlands: Elsevier BV. [ Google Scholar ]
• Robertson, A. (2007). Becoming comfortable with self: Young gays' and lesbians' lives and relationships . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/25124 [ Google Scholar ]
• Rodgers, S. (2000). Research utilisation by nurses in general medical and surgical wards . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/22600 [ Google Scholar ]
• Rukholm, E. (1999). Uncertainty, family responsibility and supportive nursing care of chronic heart failure patients and their families . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Silverman, D. (2011). Interpreting qualitative data (4th ed.). Thousand Oaks, CA: Sage. [ Google Scholar ]
• Smith, G. (1998). Counselling in inflammatory bowel disease . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/12244 [ Google Scholar ]
• Spear, H. J. (2007). Nursing theory and knowledge development: A descriptive review of doctoral dissertations, 2000–2004 . ANS Advances in Nursing Science , 30 ( 1 ), E1–E14. [ PubMed ] [ Google Scholar ]
• Stenhouse, R. (2009). Unfulfilled expectations: A narrative study of individuals' experiences of being a patient on an acute psychiatric inpatient ward in Scotland . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/4071 [ Google Scholar ]
• Tao, Y. (2014). Nursing students' attitudes towards rural nursing practice . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/9827 [ Google Scholar ]
• Teichman, J. , & Evans, K. C. (1999). Philosophy: A beginner's guide (3rd ed.). Cambridge, MA: Blackwell. [ Google Scholar ]
• Traynor, V. (2001). Understanding the lives of older women: Adjustment in later life . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/23230 [ Google Scholar ]
• Tricas‐sauras, M. (2008). Eating disorders in patients with irritable bowel syndrome: A multimethod study . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. [ Google Scholar ]
• Turner, G. (1995). Organisational climate and standards of nursing care: The administration of depot neuroleptic drugs to psychiatric out‐patients . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/21576 [ Google Scholar ]
• Vivar, C. G. (2007). Again: An account of demoralisation in patients and families experiencing recurrence of cancer . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/2151 [ Google Scholar ]
• Watchman, K. (2013). At a crossroads in care: The experience of individuals with Down syndrome and dementia . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/9549 [ Google Scholar ]
• Watson, N. T. (2001). Impairment, disablement and identity . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/23250 [ Google Scholar ]
• Yarcheski, A. , & Mahon, N. E. (2013). Characteristics of quantitative nursing research from 1990 to 2010 . Journal of Nursing Scholarship , 45 ( 4 ), 405–411. 10.1111/jnu.12038 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yarcheski, A. , Mahon, N. E. , & Yarcheski, T. J. (2012). A descriptive study of research published in scientific nursing journals from 1985 to 2010 . International Journal of Nursing Studies , 49 , 1112–1121. 10.1016/j.ijnurstu.2012.03.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zhang, J. (2014). Grounded theory analysis of hospital‐based Chinese midwives' professional identity construction . Doctoral thesis, School of Health in Social Science. University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/9823 [ Google Scholar ]
• Zhu, J. (2012). Towards an understanding of nurses leaving nursing practice in China: A qualitative exploration of nurses leaving nursing practice from recruitment to final exit . Doctoral thesis, School of Health in Social. Science, University of Edinburgh. Retrieved from https://www.era.lib.ed.ac.uk/handle/1842/7800 [ Google Scholar ]

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Why Nursing Research Matters

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• 1 Author Affiliation: Director, Magnet Recognition Program®, American Nurses Credentialing Center, Silver Spring, Maryland.
• PMID: 33882548
• DOI: 10.1097/NNA.0000000000001005

Increasingly, nursing research is considered essential to the achievement of high-quality patient care and outcomes. In this month's Magnet® Perspectives column, we examine the origins of nursing research, its role in creating the Magnet Recognition Program®, and why a culture of clinical inquiry matters for nurses. This column explores how Magnet hospitals have built upon the foundation of seminal research to advance contemporary standards that address some of the challenges faced by healthcare organizations around the world. We offer strategies for nursing leaders to develop robust research-oriented programs in their organizations.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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The author declares no conflicts of interest.

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• Research article
• Open access
• Published: 09 November 2005

A qualitative study of nursing student experiences of clinical practice

• Farkhondeh Sharif 1 &
• Sara Masoumi 2  

BMC Nursing volume  4 , Article number:  6 ( 2005 ) Cite this article

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Nursing student's experiences of their clinical practice provide greater insight to develop an effective clinical teaching strategy in nursing education. The main objective of this study was to investigate student nurses' experience about their clinical practice.

Focus groups were used to obtain students' opinion and experiences about their clinical practice. 90 baccalaureate nursing students at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery) were selected randomly from two hundred students and were arranged in 9 groups of ten students. To analyze the data the method used to code and categories focus group data were adapted from approaches to qualitative data analysis.

Four themes emerged from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap"," clinical supervision", professional role", were considered as important factors in clinical experience.

The result of this study showed that nursing students were not satisfied with the clinical component of their education. They experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting.

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Clinical experience has been always an integral part of nursing education. It prepares student nurses to be able of "doing" as well as "knowing" the clinical principles in practice. The clinical practice stimulates students to use their critical thinking skills for problem solving [ 1 ]

Awareness of the existence of stress in nursing students by nurse educators and responding to it will help to diminish student nurses experience of stress. [ 2 ]

Clinical experience is one of the most anxiety producing components of the nursing program which has been identified by nursing students. In a descriptive correlational study by Beck and Srivastava 94 second, third and fourth year nursing students reported that clinical experience was the most stressful part of the nursing program[ 3 ]. Lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. In study done by Hart and Rotem stressful events for nursing students during clinical practice have been studied. They found that the initial clinical experience was the most anxiety producing part of their clinical experience [ 4 ]. The sources of stress during clinical practice have been studied by many researchers [ 5 – 10 ] and [ 11 ].

The researcher came to realize that nursing students have a great deal of anxiety when they begin their clinical practice in the second year. It is hoped that an investigation of the student's view on their clinical experience can help to develop an effective clinical teaching strategy in nursing education.

A focus group design was used to investigate the nursing student's view about the clinical practice. Focus group involves organized discussion with a selected group of individuals to gain information about their views and experiences of a topic and is particularly suited for obtaining several perspectives about the same topic. Focus groups are widely used as a data collection technique. The purpose of using focus group is to obtain information of a qualitative nature from a predetermined and limited number of people [ 12 , 13 ].

Using focus group in qualitative research concentrates on words and observations to express reality and attempts to describe people in natural situations [ 14 ].

The group interview is essentially a qualitative data gathering technique [ 13 ]. It can be used at any point in a research program and one of the common uses of it is to obtain general background information about a topic of interest [ 14 ].

Focus groups interviews are essential in the evaluation process as part of a need assessment, during a program, at the end of the program or months after the completion of a program to gather perceptions on the outcome of that program [ 15 , 16 ]. Kruegger (1988) stated focus group data can be used before, during and after programs in order to provide valuable data for decision making [ 12 ].

The participants from which the sample was drawn consisted of 90 baccalaureate nursing students from two hundred nursing students (30 students from the second year and 30 from the third and 30 from the fourth year) at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery). The second year nursing students already started their clinical experience. They were arranged in nine groups of ten students. Initially, the topics developed included 9 open-ended questions that were related to their nursing clinical experience. The topics were used to stimulate discussion.

The following topics were used to stimulate discussion regarding clinical experience in the focus groups.

How do you feel about being a student in nursing education?

How do you feel about nursing in general?

Is there any thing about the clinical field that might cause you to feel anxious about it?

Would you like to talk about those clinical experiences which you found most anxiety producing?

Which clinical experiences did you find enjoyable?

What are the best and worst things do you think can happen during the clinical experience?

What do nursing students worry about regarding clinical experiences?

How do you think clinical experiences can be improved?

What is your expectation of clinical experiences?

The first two questions were general questions which were used as ice breakers to stimulate discussion and put participants at ease encouraging them to interact in a normal manner with the facilitator.

Data analysis

The following steps were undertaken in the focus group data analysis.

Immediate debriefing after each focus group with the observer and debriefing notes were made. Debriefing notes included comments about the focus group process and the significance of data

Listening to the tape and transcribing the content of the tape

Checking the content of the tape with the observer noting and considering any non-verbal behavior. The benefit of transcription and checking the contents with the observer was in picking up the following:

Parts of words

Non-verbal communication, gestures and behavior...

The researcher facilitated the groups. The observer was a public health graduate who attended all focus groups and helped the researcher by taking notes and observing students' on non-verbal behavior during the focus group sessions. Observer was not known to students and researcher

The methods used to code and categorise focus group data were adapted from approaches to qualitative content analysis discussed by Graneheim and Lundman [ 17 ] and focus group data analysis by Stewart and Shamdasani [ 14 ] For coding the transcript it was necessary to go through the transcripts line by line and paragraph by paragraph, looking for significant statements and codes according to the topics addressed. The researcher compared the various codes based on differences and similarities and sorted into categories and finally the categories was formulated into a 4 themes.

The researcher was guided to use and three levels of coding [ 17 , 18 ]. Three levels of coding selected as appropriate for coding the data.

Level 1 coding examined the data line by line and making codes which were taken from the language of the subjects who attended the focus groups.

Level 2 coding which is a comparing of coded data with other data and the creation of categories. Categories are simply coded data that seem to cluster together and may result from condensing of level 1 code [ 17 , 19 ].

Level 3 coding which describes the Basic Social Psychological Process which is the title given to the central themes that emerge from the categories.

Table 1 shows the three level codes for one of the theme

The documents were submitted to two assessors for validation. This action provides an opportunity to determine the reliability of the coding [ 14 , 15 ]. Following a review of the codes and categories there was agreement on the classification.

Ethical considerations

The study was conducted after approval has been obtained from Shiraz university vice-chancellor for research and in addition permission to conduct the study was obtained from Dean of the Faculty of Nursing and Midwifery. All participants were informed of the objective and design of the study and a written consent received from the participants for interviews and they were free to leave focus group if they wish.

Most of the students were females (%94) and single (% 86) with age between 18–25.

The qualitative analysis led to the emergence of the four themes from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap", clinical supervision"," professional role", was considered as important factors in clinical experience.

Initial clinical anxiety

This theme emerged from all focus group discussion where students described the difficulties experienced at the beginning of placement. Almost all of the students had identified feeling anxious in their initial clinical placement. Worrying about giving the wrong information to the patient was one of the issues brought up by students.

One of the students said:

On the first day I was so anxious about giving the wrong information to the patient. I remember one of the patients asked me what my diagnosis is. ' I said 'I do not know', she said 'you do not know? How can you look after me if you do not know what my diagnosis is?'

From all the focus group sessions, the students stated that the first month of their training in clinical placement was anxiety producing for them.

One of the students expressed:

The most stressful situation is when we make the next step. I mean ... clinical placement and we don't have enough clinical experience to accomplish the task, and do our nursing duties .

Almost all of the fourth year students in the focus group sessions felt that their stress reduced as their training and experience progressed.

Another cause of student's anxiety in initial clinical experience was the students' concern about the possibility of harming a patient through their lack of knowledge in the second year.

One of the students reported:

In the first day of clinical placement two patients were assigned to me. One of them had IV fluid. When I introduced myself to her, I noticed her IV was running out. I was really scared and I did not know what to do and I called my instructor .

Fear of failure and making mistakes concerning nursing procedures was expressed by another student. She said:

I was so anxious when I had to change the colostomy dressing of my 24 years old patient. It took me 45 minutes to change the dressing. I went ten times to the clinic to bring the stuff. My heart rate was increasing and my hand was shaking. I was very embarrassed in front of my patient and instructor. I will never forget that day .

Sellek researched anxiety-creating incidents for nursing students. He suggested that the ward is the best place to learn but very few of the learner's needs are met in this setting. Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing [ 11 ].

Theory-practice gap

The category theory-practice gap emerged from all focus discussion where almost every student in the focus group sessions described in some way the lack of integration of theory into clinical practice.

I have learnt so many things in the class, but there is not much more chance to do them in actual settings .

Another student mentioned:

When I just learned theory for example about a disease such as diabetic mellitus and then I go on the ward and see the real patient with diabetic mellitus, I relate it back to what I learned in class and that way it will remain in my mind. It is not happen sometimes .

The literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly [ 20 , 21 ]. The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap [ 21 ]. Rolfe suggests that by reconsidering the relationship between theory and practise the gap can be closed. He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theory-practice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practising nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalise from what they learnt in theory [ 22 ].

Clinical supervision

Clinical supervision is recognised as a developmental opportunity to develop clinical leadership. Working with the practitioners through the milieu of clinical supervision is a powerful way of enabling them to realize desirable practice [ 23 ]. Clinical nursing supervision is an ongoing systematic process that encourages and supports improved professional practice. According to Berggren and Severinsson the clinical nurse supervisors' ethical value system is involved in her/his process of decision making. [ 24 , 25 ]

Clinical Supervision by Head Nurse (Nursing Unit Manager) and Staff Nurses was another issue discussed by the students in the focus group sessions. One of the students said:

Sometimes we are taught mostly by the Head Nurse or other Nursing staff. The ward staff are not concerned about what students learn, they are busy with their duties and they are unable to have both an educational and a service role

Another student added:

Some of the nursing staff have good interaction with nursing students and they are interested in helping students in the clinical placement but they are not aware of the skills and strategies which are necessary in clinical education and are not prepared for their role to act as an instructor in the clinical placement

The students mostly mentioned their instructor's role as an evaluative person. The majority of students had the perception that their instructors have a more evaluative role than a teaching role.

The literature suggests that the clinical nurse supervisors should expressed their existence as a role model for the supervisees [ 24 ]

Professional role

One view that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

We just do basic nursing care, very basic . ... You know ... giving bed baths, keeping patients clean and making their beds. Anyone can do it. We spend four years studying nursing but we do not feel we are doing a professional job .

The role of the professional nurse and nursing auxiliaries was another issue discussed by one of the students:

The role of auxiliaries such as registered practical nurse and Nurses Aids are the same as the role of the professional nurse. We spend four years and we have learned that nursing is a professional job and it requires training and skills and knowledge, but when we see that Nurses Aids are doing the same things, it can not be considered a professional job .

The result of student's views toward clinical experience showed that they were not satisfied with the clinical component of their education. Four themes of concern for students were 'initial clinical anxiety', 'theory-practice gap', 'clinical supervision', and 'professional role'.

The nursing students clearly identified that the initial clinical experience is very stressful for them. Students in the second year experienced more anxiety compared with third and fourth year students. This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of anxiety in second year [ 26 , 27 ]. Neary identified three main categories of concern for students which are the fear of doing harm to patients, the sense of not belonging to the nursing team and of not being fully competent on registration [ 28 ] which are similar to what our students mentioned in the focus group discussions. Jinks and Patmon also found that students felt they had an insufficiency in clinical skills upon completion of pre-registration program [ 29 ].

Initial clinical experience was the most anxiety producing part of student clinical experience. In this study fear of making mistake (fear of failure) and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. This finding is supported by Hart and Rotem [ 4 ] and Stephens [ 30 ]. Developing confidence is an important component of clinical nursing practice [ 31 ]. Development of confidence should be facilitated by the process of nursing education; as a result students become competent and confident. Differences between actual and expected behaviour in the clinical placement creates conflicts in nursing students. Nursing students receive instructions which are different to what they have been taught in the classroom. Students feel anxious and this anxiety has effect on their performance [ 32 ]. The existence of theory-practice gap in nursing has been an issue of concern for many years as it has been shown to delay student learning. All the students in this study clearly demonstrated that there is a gap between theory and practice. This finding is supported by other studies such as Ferguson and Jinks [ 33 ] and Hewison and Wildman [ 34 ] and Bjork [ 35 ]. Discrepancy between theory and practice has long been a source of concern to teachers, practitioners and learners. It deeply rooted in the history of nurse education. Theory-practice gap has been recognised for over 50 years in nursing. This issue is said to have caused the movement of nurse education into higher education sector [ 34 ].

Clinical supervision was one of the main themes in this study. According to participant, instructor role in assisting student nurses to reach professional excellence is very important. In this study, the majority of students had the perception that their instructors have a more evaluative role than a teaching role. About half of the students mentioned that some of the head Nurse (Nursing Unit Manager) and Staff Nurses are very good in supervising us in the clinical area. The clinical instructor or mentors can play an important role in student nurses' self-confidence, promote role socialization, and encourage independence which leads to clinical competency [ 36 ]. A supportive and socialising role was identified by the students as the mentor's function. This finding is similar to the finding of Earnshaw [ 37 ]. According to Begat and Severinsson supporting nurses by clinical nurse specialist reported that they may have a positive effect on their perceptions of well-being and less anxiety and physical symptoms [ 25 ].

The students identified factors that influence their professional socialisation. Professional role and hierarchy of occupation were factors which were frequently expressed by the students. Self-evaluation of professional knowledge, values and skills contribute to the professional's self-concept [ 38 ]. The professional role encompasses skills, knowledge and behaviour learned through professional socialisation [ 39 ]. The acquisition of career attitudes, values and motives which are held by society are important stages in the socialisation process [ 40 ]. According to Corwin autonomy, independence, decision-making and innovation are achieved through professional self-concept 41 . Lengacher (1994) discussed the importance of faculty staff in the socialisation process of students and in preparing them for reality in practice. Maintenance and/or nurturance of the student's self-esteem play an important role for facilitation of socialisation process 42 .

One view that was expressed by second and third year student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

The finding of this study and the literature support the need to rethink about the clinical skills training in nursing education. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. There were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education. Nursing students expressed their views and mentioned their worry about the initial clinical anxiety, theory-practice gap, professional role and clinical supervision. They mentioned that integration of both theory and practice with good clinical supervision enabling them to feel that they are enough competent to take care of the patients. The result of this study would help us as educators to design strategies for more effective clinical teaching. The results of this study should be considered by nursing education and nursing practice professionals. Faculties of nursing need to be concerned about solving student problems in education and clinical practice. The findings support the need for Faculty of Nursing to plan nursing curriculum in a way that nursing students be involved actively in their education.

Dunn SV, Burnett P: The development of a clinical learning environment scale. Journal of Advanced Nursing. 1995, 22: 1166-1173.

Article   CAS   PubMed   Google Scholar  

Lindop E: Factors associated with student and pupil nurse wastage. Journal of Advanced Nursing. 1987, 12 (6): 751-756.

Beck D, Srivastava R: Perceived level and source of stress in baccalaureate nursing students. Journal of Nursing Education. 1991, 30 (3): 127-132.

CAS   PubMed   Google Scholar  

Hart G, Rotem A: The best and the worst: Students' experience of clinical education. The Australian Journal of Advanced Nursing. 1994, 11 (3): 26-33.

Sheila Sh, Huey-Shyon L, Shiowli H: Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice. International Journal of Nursing Studies. 2002, 39: 165-175. 10.1016/S0020-7489(01)00016-5.

Article   Google Scholar  

Johnson J: Reducing distress in first level and student nurses. Journal of Advanced Nursing. 2000, 32 (1): 66-74. 10.1046/j.1365-2648.2000.01421.x.

Admi H: Nursing students' stress during the initial clinical experience. Journal of Nursing Education. 1997, 36: 323-327.

Blainey GC: Anxiety in the undergraduate medical-surgical clinical student. Journal of Nursing Education. 1980, 19 (8): 33-36.

Wong J, Wong S: Towards effective clinical teaching in nursing. Journal of Advanced Nursing. 1987, 12 (4): 505-513.

Windsor A: Nursing students' perceptions of clinical experience. Journal of Nursing Education. 1987, 26 (4): 150-154.

Sellek T: Satisfying and anxiety creating incidents for nursing students. Nursing Times. 1982, 78 (35): 137-140.

PubMed   Google Scholar  

Krueger RA: Focus Groups: A Practical Guide for Applied Research. Sage Publications: California. 1988

Google Scholar  

Denzin NK: The Research Act. 1989, Prentice Hall: Englewood Cliffs, New Jersey, 3

Stewart DW, Shamdasani PN: Analysing focus group data. Focus Groups: Theory and Practice. Edited by: Shamdasani PN. 1990, Sage Publications: Newbury Park

Barbour RS, Kitzinger J: Developing focus group research : politics, theory and practice. Sage. 1999

Patton MQ: Qualitative Evaluation and Research Methods. 1990, Sage publications, 2

Graneheim UH, Lundman B: Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004, 24: 105-112. 10.1016/j.nedt.2003.10.001.

Streubert HJ, Carpenter DR: Qualitative Research in Nursing. Advancing the Humanistic Imperative. 1995, J.B. Lippincott Company: Philadelphia

Polit DF, Hungler BP: Nursing research: Principles and Methods. Philadelphia newyork. 1999

Allmark PA: classical view of the theory-practice gap in nursing. Journal of Advanced Nursing. 1995, 22 (1): 18-23. 10.1046/j.1365-2648.1995.22010018.x.

Tolley KA: Theory from practice for practice: Is this a reality?. Journal of Advanced Nursing. 1995, 21 (1): 184-190. 10.1046/j.1365-2648.1995.21010184.x.

Rolfe G: Listening to students: Course evaluation as action research. Nurse Education Today. 1994, 14 (3): 223-227. 10.1016/0260-6917(94)90085-X.

Johns Ch: clinical supervision as a model for clinical leadership. Journal of Nursing Management. 2003, 11: 25-34. 10.1046/j.1365-2834.2002.00288.x.

Article   PubMed   Google Scholar  

Berggren I, Severinsson E: Nurses supervisors'action in relation to their decision-making style and ethical approach to clinical supervision. Journal of Advanced Nursing. 2003, 41 (6): 615-622. 10.1046/j.1365-2648.2003.02573.x.

Begat I, Severinsson E: Nurses' satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being. Journal of Nursing Management. 2005, 13: 221-230. 10.1111/j.1365-2834.2004.00527.x.

Bell P: Anxiety in mature age and higher school certificate entry student nurses – A comparison of effects on performance. Journal of Australian Congress of Mental Health Nurses. 1984, 4/5: 13-21.

Ruth L: Experiencing before and throughout the nursing career. Journal of Advanced Nursing. 2002, 39: 119-10.1046/j.1365-2648.2000.02251.x.

Neary M: Project 2000 students' survival kit: a return to the practical room. Nurse Education Today. 1997, 17 (1): 46-52. 10.1016/S0260-6917(97)80078-0.

Jinks A, Pateman B: Nither this nor that: The stigma of being an undergraduate nurse. Nursing Times. 1998, 2 (2): 12-13.

CAS   Google Scholar  

Stephen RL: Imagery: A treatment for nursing student anxiety. Journal of Nursing Education. 1992, 31 (7): 314-319.

Grundy SE: The confidence scale. Nurse Educator. 1993, 18 (1): 6-9.

Copeland L: Developing student confidence. Nurse Educator. 1990, 15 (1): 7-

Ferguson K, Jinks A: Integrating what is taught with what is practised in the nursing curriculum: A multi-dimensional model. Journal of Advanced Nursing. 1994, 20 (4): 687-695. 10.1046/j.1365-2648.1994.20040687.x.

Hewison A, Wildman S: The theory-practice gap in nursing: A new dimension. Journal of Advanced Nursing. 1996, 24 (4): 754-761. 10.1046/j.1365-2648.1996.25214.x.

Bjork T: Neglected conflicts in the discipline of nursing: Perceptions of the importance and value of practical skill. Journal of Advanced Nursing. 1995, 22 (1): 6-12. 10.1046/j.1365-2648.1995.22010006.x.

Busen N: Mentoring in advanced practice nursing. Journal of Advanced Nursing Practice. 1999, 2: 2-

Earnshaw GP: Mentorship: The students' view. Nurse Education Today. 1995, 15 (4): 274-279. 10.1016/S0260-6917(95)80130-8.

Kelly B: The professional self-concepts of nursing undergraduates and their perceptions of influential forces. Journal of Nursing Education. 1992, 31 (3): 121-125.

Lynn MR, McCain NL, Boss BJ: Socialization of R.N. to B.S.N Image:. Journal of Nursing Scholarship. 1989, 21 (4): 232-237.

Article   CAS   Google Scholar  

Klein SM, Ritti RR: Understanding Organisational Behaviour. 1980, Kent: Boston

Corwin RG: The professional employee: A study of conflict in nursing roles. The American Journal of Sociology. 1961, 66: 604-615. 10.1086/223010.

Lengacher CA: Effects of professional development seminars on role conception, role deprivation, and self-esteem of generic baccalaureate students. Nursing Connections. 1994, 7 (1): 21-34.

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Sharif, F., Masoumi, S. A qualitative study of nursing student experiences of clinical practice. BMC Nurs 4 , 6 (2005). https://doi.org/10.1186/1472-6955-4-6

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How Does Research Start?

Capili, Bernadette PhD, NP-C

Bernadette Capili is director of the Heilbrunn Family Center for Research Nursing, Rockefeller University, New York City. This manuscript was supported in part by grant No. UL1TR001866 from the National Institutes of Health's National Center for Advancing Translational Sciences Clinical and Translational Science Awards Program. Contact author: [email protected] . The author has disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com .

Editor's note: This is the first article in a new series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice—from research design to data interpretation. The articles will also be accompanied by a podcast offering more insight and context from the author.

This article—the first in a new series on clinical research by nurses—focuses on how to start the research process by identifying a topic of interest and developing a well-defined research question.

Clinical research aims to deliver health care advancements that are “safe, beneficial, and cost-effective.” 1 It applies a methodical approach to developing studies that generate high-quality evidence to support changes in clinical practice. This is a stepwise process that attempts to limit the chances of errors, random or systematic, that can compromise conclusions and invalidate findings. 2 Nurses need to be well versed in the research in their field in order to find the best evidence to guide their clinical practice and to develop their own research. To effectively use the literature for these purposes, it is imperative to understand the principles of critical appraisal and basic study design.

There are many roles for nurses in research. Nurses can be consumers who stay abreast of current issues and trends in their specialty area, nurse champions who initiate quality improvement projects guided by the best clinical evidence, members of an interprofessional research team helping to address a complex health problem, or independent nurse scientists developing a line of scientific inquiry. Regardless of the nurse's role, a common goal of clinical research is to understand health and illness and to discover novel methods to detect, diagnose, treat, and prevent disease.

This column is the first in a series on the concepts of clinical research using a step-by-step approach. Each column will build on earlier columns to provide an overview of the essential components of clinical research. The focus of this inaugural column is how to start the research process, which involves the identification of the topic of interest and the development of a well-defined research question. This article also discusses how to formulate quantitative and qualitative research questions.

IDENTIFYING A TOPIC OF INTEREST

The motivation to explore an area of inquiry often starts with an observation that leads to questioning why something occurs or what would happen if we tried a different approach. Speaking to patients and hearing their concerns about how to manage specific conditions or symptoms is another way to be inspired. Exploring new technologies, examining successful techniques, and adapting the procedures of other fields or disciplines can be other sources for new insights and discoveries. 2 Nurses working in a cardiac setting, for example, may take an interest in using fitness watches to monitor adherence to a walking program to reduce blood pressure and body weight. Their ease of use, cost, and availability may be what draws nurses to exploring the potential uses of this technology. Since the goal of research is to improve patients' lives, it's vital that anyone engaging in clinical research be curious and willing to understand clinical issues and explore the problems that need solving.

Reviewing the literature . Developing a research project requires in-depth knowledge of the chosen area of inquiry (for example, the etiology and treatment of hypertension, which is the hypothetical area of inquiry in this article). Ways to become immersed in the topic include speaking to experts in the field and conducting a comprehensive literature review. Two main types of review found in the literature are narrative and systematic.

Narrative reviews present an overview of current issues and trends in the area of interest and can address clinical, background, or theoretical questions. They can summarize current findings, identify gaps in research, and provide suggestions for next steps. 3 On the downside, narrative reviews can be biased because they are based on the author's experience and interpretation of findings and lack systematic and objective selection criteria. 4

Systematic reviews differ from narrative reviews in that they use a systematic approach to select, appraise, and evaluate the literature. Systematic reviews start with a clinical question to be answered by the review. They use clearly defined criteria to determine which articles to include and which to exclude. Systematic reviews can help nurses understand what works and what doesn't in terms of intervention-based research, and they are excellent resources if an area of inquiry is an intervention-based project. (For the categories of interventional studies, see Table 1 .)

Reviewing citations from published papers is another way to find relevant publications. A frequently cited publication in a particular area may indicate a landmark paper in which the authors present an important discovery or identify a critical issue. An essential goal of the literature review is to ensure that previous studies in the area of interest are located and understood. Previous studies provide insight into recent discoveries in the field, as well as into the dilemmas and challenges others encountered in conducting the research.

DEVELOPING THE RESEARCH QUESTION

The two main branches of research methods are experimental and observational. Randomized controlled trials and non–randomized controlled trials belong in the experimental category, while analytical studies with control groups and descriptive studies without control groups belong in the observational category. Types of analytical studies include cohort and case–control studies; types of descriptive studies include ecological and cross-sectional studies, and case reports.

Despite their differences, the common thread among these research methods is the research question. This question helps guide the study design and is the foundation for developing the study. In the health sciences, the question needs to pass the “So what?” test. That is, is the issue relevant, is studying it feasible, and will it advance the field?

Cummings and colleagues use the mnemonic FINER ( F easible, I nteresting, N ovel, E thical, R elevant) to define the characteristics of a good research question. 2

Feasible . Feasibility is a critical element of research. Research questions must be answerable and focus on clear approaches to measuring or quantifying change or outcome. For example, assessing blood pressure for a study on the benefits of reducing hypertension is feasible because methods to measure blood pressure, the stages of hypertension, and the positive results associated with achieving normal blood pressure are established. For research requiring human participants, approaches to recruiting and enrolling them in the study require careful planning. Strategies must consider where and how to recruit the best participants to fit the study population under investigation. In addition, an adequate number of study participants is necessary in order to conduct the study. The allotted time frame to complete the study, the workforce to perform the study, and the budget to conduct the study must also be realistic. Research studies funded by private or public sponsors usually have defined time frames to completion, such as two or three years. Funders may also request a timeline showing when various aspects of the research will be achieved (institutional review board [IRB] approval, recruitment of participants, data analysis, and so on).

Interesting . Several factors may drive a researcher's interest in an area of inquiry. Cummings and colleagues use the term interesting to describe an area the investigator believes is important to examine. 2 For some investigators, an experience or an observation is the motivation for evaluating the underpinnings of a situation or condition. For some, the possibility of obtaining financial support, either through private or public funding, is an important consideration in choosing a research question or study subject. For others, pursuing a particular research question is the logical next step in their program of research.

Novel . Novel research implies that the study provides new information that contributes to or advances a field of inquiry. This may include research that confirms or refutes earlier study results or that replicates past research to validate scientific findings. When replicating studies, improving previously used research methods (for example, increasing sample size, outcome measures, or the follow-up period) can strengthen the project. A study replicating an earlier hypertension study may add a way to assess dietary sodium intake physiologically instead of only by collecting food records.

Ethical . It is mandatory that research proceed in an ethical manner, from the protection of human and animal subjects to data collection, data storage, and the reporting of research results. Research studies must obtain IRB approval before they can proceed. The IRB is an ethics committee that reviews the proposed research plan to ensure it has adequate safeguards for the well-being of the study participants. It also evaluates the potential risk versus benefit of the proposed study. If the level of risk posed by the study outweighs the benefits of the potential outcome, the IRB may require changes to the research plan to improve the safety profile, or it may reject the study. For example, an IRB may not approve a study proposing to use a placebo for comparison when well-established and effective treatments are available. The National Institutes of Health offers an excellent educational resource, Clinical Research Training ( https://ocr.od.nih.gov/clinical_research_training.html ), a free online tutorial on ethics, patient safety, protocol implementation, and regulatory research. Registration is required and each module takes 15 to 90 minutes to complete.

Relevant . Relevant research questions address critical issues. A relevant question will add to the current knowledge in the field. It may also change clinical practice or influence policy. The question must be timely and appropriate for the study population under investigation. For instance, to continue our hypothetical hypertension study example, for individuals diagnosed with hypertension, it is recognized that reducing the dietary intake of sodium and increasing potassium can lower blood pressure and reduce the risk of heart disease and stroke. Therefore, in conducting a dietary study to reduce blood pressure, an investigator might target the intakes of both sodium and potassium. Focusing solely on one and not the other ignores the best available evidence in the field.

GUIDELINES FOR QUESTION DEVELOPMENT: PICO, PEO

Guidelines are available to help frame the research question, and PICO and PEO are among the most common. PICO is best suited for quantitative studies, while PEO is appropriate for qualitative studies. Quantitative and qualitative methodologies approach research using different lenses. In quantitative research, numerical data is produced, necessitating statistical analysis. Qualitative research generates themes, and the outcome of interest is the understanding of phenomena and experiences. It's important to note that some topics may not fit the PICO or PEO frameworks. In those cases, novice researchers may want to consult with a mentor or academic research adviser for help in formulating the research question.

PICO questions incorporate the following components: P opulation, I ntervention, C omparison, and O utcome.

• Population is the people or community affected by a specific health condition or problem (for instance, middle-age adults ages 45 to 65 with stage 1 hypertension, or older adults ages 65 and older with stage 1 hypertension living in nursing homes).
• Intervention is the process or action under investigation. Interventions can be pharmaceutical agents, devices, or procedures; changes in a process; or patient education on diet and exercise. They can be either investigational or already available to consumers or health care professionals.
• Comparison means the group or intervention being compared with the intervention under investigation (for instance, those eating a vegan diet compared with those eating a Mediterranean-style diet).
• Outcome is the planned measure to determine the effect of an intervention on the population under study. For example, in the study comparing a vegan diet with a Mediterranean-style diet, the outcomes of interest could be the percent reductions in body weight and blood pressure.
• PEO questions incorporate the following components: P opulation, E xposure, and O utcome.
• Population centers on those affected and their problems (for example, middle-age adults who have hypertension and smoke).
• Exposure focuses on the area of interest (for example, experience with smoking cessation programs or triggers of smoking). Since qualitative studies can denote a broad area of research or specific subcategories of topics, the exposure viewpoint depends on the framing or wording of the research question and the goals of the project. 5
• Outcome might encompass a person's experience with smoking cessation and the themes associated with quitting and relapsing. Since the PEO model is best suited for qualitative studies, the outcome tends to include the definition of a person's experiences in certain areas or discover processes that happen in specific locations or contexts. 6

How to formulate a research question using the PICO and PEO frameworks is reviewed in Table 2 .

GOING FORWARD

This has been a brief review of how to find an area of interest for your research and how to form an effective research question. For some, the inspiration for research will come from observations and experiences in the work setting, colleagues, investigations in other fields, and past research. As has been noted, before delving into developing a research protocol it's important to master the subject of interest by speaking with experts and gaining a firm understanding of the literature in the field. Then, consider using the FINER mnemonic as a guide to determine if your research question can pass the “So what?” test and the PICO or PEO model to structure the question. Formulating the appropriate research question is vital to conducting your research because the question is the starting point to selecting the study design, population of interest, interventions or exposure, and outcomes. The next column will discuss the process for selecting the study participants.

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